Less than meets the eye: reappraising the clinical relevance of attentional bias in addiction

Changes of attentional bias in patients with alcohol use disorder during abstinence: A longitudinal study

BACKGROUND

Alcohol Use Disorder (AUD) is linked to an attentional bias towards alcohol-related cues (e.g. images, smells), which acquire incentive properties and promote continued consumption.

METHOD

We investigated how the general and alcohol attentional bias evolved longitudinally in AUD patients along two periods of abstinence: t = 0 (baseline, 1-3 months of abstinence) and t = 1 (follow-up; 6 months of abstinence), as well as their relationship with alcohol-related variables. General and alcohol-specific attentional bias were evaluated by the Classic and the Alcohol Stroop tests (neutral and alcohol conditions) in abstinent AUD patients and controls.

RESULTS

At t = 0, the AUD group exhibited both general and alcohol-specific attentional biases, with greater effect in the general bias. At t = 1, alcohol-specific attentional bias decreased specifically in the AUD group and reached control levels (with interference index levels increasing from 1-3 months to 6 months). However, general attentional bias showed a trend toward improvement but it did not significantly change through abstinence process (linear mixed models, controlling for age, BMI, sex and education).

CONCLUSIONS

In AUD patients, general and alcohol attentional biases exhibit different trajectories during abstinence, with the attentional bias toward alcohol improving significantly throughout this process whereas general attentional bias is maintained.

Behavioral therapies targeting reward mechanisms in substance use disorders

Behavioral therapies are considered best practices in the treatment of substance use disorders (SUD) and used as first-line approaches for SUDs without FDA-approved pharmacotherapies. Decades of research on the neuroscience of drug reward and addiction have informed the development of current leading behavioral therapies that, while differing in focus and technique, have in common the overarching goal of shifting reward responding away from drug and toward natural non-drug rewards. This review begins by describing key neurobiological processes of reward in addiction, followed by a description of how various behavioral therapies address specific reward processes. Based on this review, a conceptual 'map' is crafted to pinpoint gaps and areas of overlap, serving as a guide for selecting and integrating behavioral therapies.

Direct Effects of Cannabis Intoxication on Motivations for Softer and Harder Drug Use: An Experimental Approach to the Gateway Hypothesis

Aims: This study experimentally tested whether there is a gateway-type effect of cannabis administration on tobacco and cocaine motivation and whether motivational responses predicted use 6 months later. Methods: A 2 (condition: active cannabis vs. placebo joint)×3 (substance stimulus type: tobacco, cannabis, and cocaine) factor within-subjects design for both implicit and explicit motivation. Both experimental sessions were conducted in a cannabis dispensary ("coffeeshop") in Amsterdam and were separated by ∼1 week, followed by a 6-month online follow-up. Eighty-five participants between 18 and 27 years of age (57% male), who used cannabis, tobacco, and cocaine <15 times per month, participated in session 1 (session 2: N=79 and follow-up: N=81). Counterbalanced over sessions, participants smoked an active and a placebo joint following a paced puffing procedure. Before and after smoking, craving and avoidance (explicit motivation) were assessed using visual analog scales, and after smoking, the stimulus response compatibility test was completed to assess approach biases (implicit motivation). Self-reported intoxication and similarity to their usual smoking experience were assessed at the end of both sessions. Self-reported frequency/quantity and dependence symptoms for tobacco, cannabis, and cocaine were assessed at all time points. A linear mixed model approach was used to assess the effects of condition, substance stimulus type, and their interactions on explicit and implicit motivation. Results: In the active condition, participants reported higher levels of intoxication and an experience more similar to their usual smoking experience than in the placebo condition. There was no significant effect of condition, substance type, or their interaction on approach bias. Participants exhibited increased cannabis craving during the placebo condition only and increased explicit cannabis avoidance during the active condition only. Explicit tobacco avoidance decreased during both conditions. Baseline measures did not predict use at 6-month follow-up. Conclusions: In light users, cannabis intoxication did not affect implicit and explicit tobacco or cocaine motivations. Tobacco avoidance decreased regardless of condition, indicating that the cannabis cue-rich setting-rather than tetrahydrocannabinol itself-may momentarily increase the likelihood to smoke tobacco. However, motivation at baseline did not predict use 6 months later, deeming any gateway-like function unlikely.

The acute effects of cannabis, with and without cannabidiol, on attentional bias to cannabis related cues: a randomised, double-blind, placebo-controlled, cross-over study

RATIONALE

Attentional bias to drug-related stimuli is hypothesised to contribute towards addiction. However, the acute effects of Δ9-tetrahydrocannabinol (THC) on attentional bias to cannabis cues, the differential response in adults and adolescents, and the moderating effect of cannabidiol (CBD) are unknown.

OBJECTIVES

Our study investigated (1) the acute effects of vaporised cannabis on attentional bias to cannabis-related images in adults and adolescents and (2) the moderating influences of age and CBD.

METHODS

We conducted a randomised, double-blind, placebo-controlled, cross-over study where three weight-adjusted vaporised cannabis preparations: 'THC' (8 mg THC for a 75-kg person), 'THC + CBD' (8 mg THC and 24 mg CBD for a 75-kg person) and PLA (matched placebo). Cannabis was administered on 3 separate days to 48 participants, who used cannabis 0.5-3 days/week: 24 adolescents (12 females, aged 16-17) and 24 adults (12 females, aged 26-29). Participants completed a visual probe task with cannabis cues. Our primary outcome was attentional bias to cannabis stimuli, measured using the differential reaction time to a cannabis vs. neutral probe, on 200-ms trials.

RESULTS

In contrast to hypotheses, attention was directed away from cannabis cues on placebo, and there was a main effect of the drug (F(2,92) = 3.865, p = 0.024, η2p = 0.077), indicating THC administration eliminated this bias. There was no significant impact of CBD nor an age-by-drug interaction.

CONCLUSIONS

Acute THC intoxication eliminated attentional bias away from cannabis cues. There was no evidence of differential response in adolescents compared to adults and no evidence that a moderate vaporised dose of CBD altered the impact of cannabis on attentional bias.

TRIAL REGISTRATION

This study was listed with the US National Library of Medicine and registered on ClinicalTrials.gov, URL: Do Adolescents and Adults Differ in Their Acute Response to Cannabis?-Full Text View-ClinicalTrials.gov, registration number: NCT04851392.

Online photography intervention reduces internet addiction during COVID-19: A randomised controlled trial

The COVID-19 pandemic has escalated concerns regarding internet addiction. This study investigated the impact of an online photograph intervention on internet addiction and identified its effectiveness mechanisms. Individuals diagnosed with internet addiction (internet addiction test score > 36, Mage = 22.85, 78.6% women) were randomly allocated to either the intervention (n = 64) or control (n = 81) groups. For 10 days, the intervention group was tasked with photographing "things that make you feel a sense of control in life" and writing 100-word descriptions explaining the reason for the sense of control elicited by the image. Meanwhile, the control group participated only in the assessments. Assessments were conducted before the intervention, immediately afterward and 7 days later. A significant interaction between group and time was observed, with the intervention group showing a notable reduction in internet addiction and an increase in sense of control. The sense of control at post-test significantly mediated the intervention's effect on reducing internet addiction at follow-up, but only among individuals with high perceived social support. The findings indicate that online photography interventions can effectively diminish internet addiction, with a sense of control acting as a potent mechanism for intervention, particularly in individuals with substantial perceived social support.

Exploring the multiverse of analysis options for the alcohol Stroop

The alcohol Stroop is a widely used task in addiction science to measure the theoretical concept of attentional bias (a selective attention to alcohol-related cues in the environment), which is thought to be associated with clinical outcomes (craving and consumption). However, recent research suggests findings from this task can be equivocal. This may be because the task has many different potential analysis pipelines, which increase researcher degrees of freedom when analysing data and reporting results. These analysis pipelines largely come from how outlying reaction times on the task are identified and handled (e.g. individual reaction times > 3 standard deviations from the mean are removed from the distribution; removal of all participant data if > 25% errors are made). We used specification curve analysis across two alcohol Stroop datasets using alcohol-related stimuli (one published and one novel) to examine the robustness of the alcohol Stroop effect to different analytical decisions. We used a prior review of this research area to identify 27 unique analysis pipelines. Across both data sets, the pattern of results was similar. The alcohol Stroop effect was present and largely robust to different analysis pipelines. Increased variability in the Stroop effect was observed when implementing outlier cut-offs for individual reaction times, rather than the removal of participants. Stricter outlier thresholds tended to reduce the size of the Stroop interference effect. These specification curve analyses are the first to examine the robustness of the alcohol Stroop to different analysis strategies, and we encourage researchers to adopt such analytical methods to increase confidence in their inferences across cognitive and addiction science.

Intermittent theta burst stimulation and functional connectivity in people living with HIV/AIDS who smoke tobacco cigarettes: a preliminary pilot study

Background

People living with HIV (PLWHA) smoke at three times the rate of the general population and respond poorly to cessation strategies. Previous studies examined repetitive transcranial magnetic stimulation (rTMS) over left dorsolateral prefrontal cortex (L. dlPFC) to reduce craving, but no studies have explored rTMS among PLWHA who smoke. The current pilot study compared the effects of active and sham intermittent theta-burst stimulation (iTBS) on resting state functional connectivity (rsFC), cigarette cue attentional bias, and cigarette craving in PLWHA who smoke.

Methods

Eight PLWHA were recruited (single-blind, within-subject design) to receive one session of iTBS (n=8) over the L. dlPFC using neuronavigation and, four weeks later, sham iTBS (n=5). Cigarette craving and attentional bias assessments were completed before and after both iTBS and sham iTBS. rsFC was assessed before iTBS (baseline) and after iTBS and sham iTBS.

Results

Compared to sham iTBS, iTBS enhanced rsFC between the L. dlPFC and bilateral medial prefrontal cortex and pons. iTBS also enhanced rsFC between the right insula and right occipital cortex compared to sham iTBS. iTBS also decreased cigarette craving and cigarette cue attentional bias.

Conclusion

iTBS could potentially offer a therapeutic option for smoking cessation in PLWHA.

Predictive utility of the P3 event-related potential (ERP) response to alcohol cues for ecologically assessed alcohol craving and use

Neural measures of alcohol cue incentive salience have been associated with retrospective reports of riskier alcohol use behaviour and subjective response profiles. This study tested whether the P3 event-related potential (ERP) elicited by alcohol-related cues (ACR-P3) can forecast alcohol use and craving during real-world drinking episodes. Participants (N = 262; Mage  = 19.53; 56% female) completed a laboratory task in which they viewed images of everyday objects (Neutral), non-alcohol drinks (NonAlc) and alcohol beverages (Alc) while EEG was recorded and then completed a 21-day ecological momentary assessment (EMA) protocol in which they recorded alcohol craving and consumption. Anthropometrics were used to derive estimated blood alcohol concentration (eBAC) throughout drinking episodes. Multilevel modelling indicated positive associations between P3 amplitudes elicited by all stimuli and within-episode alcohol use measures (e.g., eBAC, cumulative drinks). Focal follow-up analyses indicated a positive association between AlcP3 amplitude and eBAC within episodes: Larger AlcP3 was associated with a steeper rise in eBAC. This association was robust to controlling for the association between NonAlcP3 and eBAC. AlcP3 also was positively associated with episode-level measures (e.g., max drinks, max eBAC). There were no associations between any P3 variables and EMA-based craving measures. Thus, individual differences in neural measures of alcohol cue incentive salience appear to predict the speed and intensity of alcohol consumption but not reports of craving during real-world alcohol use episodes.

Cannabidiol does not attenuate acute delta-9-tetrahydrocannabinol-induced attentional bias in healthy volunteers: A randomised, double-blind, cross-over study

AIMS

To test how attentional bias and explicit liking are influenced by delta-9-tetrahydrocannabinol (THC) and whether these effects are moderated by cannabidiol (CBD).

DESIGN

Double-blind, randomised, within-subjects cross-over study.

SETTING

NIHR Wellcome Trust Clinical Research Facility at King's College Hospital, London, United Kingdom.

PARTICIPANTS/CASES

Forty-six infrequent cannabis users (cannabis use <1 per week).

INTERVENTION(S)

Across four sessions, participants inhaled vaporised cannabis containing 10 mg of THC and either 0 mg (0:1 CBD:THC), 10 mg (1:1), 20 mg (2:1) or 30 mg (3:1) of CBD, administered in a randomised order and counter-balanced across participants (a total of 24 order groups).

MEASUREMENTS

Participants completed two tasks: (1) Attentional Bias (AB), comparing reaction times toward visual probes presented behind 28 target stimuli (cannabis/food) compared with probes behind corresponding non-target (neutral) stimuli. Participants responding more quickly to probes behind target than non-target stimuli would indicate greater attentional bias to cannabis/food; (2) Picture Rating (PR), where all AB stimuli were rated on a 7-point pleasantness scale, measuring explicit liking.

FINDINGS

During the AB task, participants were more biased toward cannabis stimuli in the 0:1 condition compared with baseline (mean difference = 12.2, 95% confidence intervals [CIs] = 1.20-23.3, d = 0.41, P = 0.03). No other significant AB or PR differences were found between cannabis and food stimuli between baseline and 0:1 condition (P > 0.05). No significant CBD effect was found on AB or PR task performance at any dose (P > 0.05). There was additionally no cumulative effect of THC exposure on AB or PR outcomes (P > 0.05).

CONCLUSIONS

A double-blind, randomised, cross-over study among infrequent cannabis users found that inhaled delta-9-tetrahydrocannabinol increased attentional bias toward cannabis in the absence of explicit liking, a marker of liability toward cannabis use disorder. At the concentrations normally found in legal and illegal cannabis, cannabidiol had no influence on this effect.

Craving modulates attentional bias towards alcohol in severe alcohol use disorder: An eye-tracking study

BACKGROUND AND AIMS

Competing models disagree on three theoretical questions regarding alcohol-related attentional bias (AB), a key process in severe alcohol use disorder (SAUD): (1) is AB more of a trait (fixed, associated with alcohol use severity) or state (fluid, associated with momentary craving states) characteristic of SAUD; (2) does AB purely reflect the over-activation of the reflexive/reward system or is it also influenced by the activity of the reflective/control system and (3) does AB rely upon early or later processing stages? We addressed these issues by investigating the time-course of AB and its modulation by subjective craving and cognitive load in SAUD.

DESIGN

A free-viewing eye-tracking task, presenting pictures of alcoholic and non-alcoholic beverages, combined with a concurrent cognitive task with three difficulty levels.

SETTING

A laboratory setting in the detoxification units of three Belgian hospitals.

PARTICIPANTS

We included 30 patients with SAUD self-reporting craving at testing time, 30 patients with SAUD reporting a total absence of craving and 30 controls matched on sex and age. All participants from SAUD groups met the DSM-5 criteria for SAUD.

MEASUREMENTS

We assessed AB through early and late eye-tracking indices. We evaluated the modulation of AB by craving (comparison between patients with/without craving) and cognitive load (variation of AB with the difficulty level of the concurrent task).

FINDINGS

Dwell time measure indicated that SAUD patients with craving allocated more attention towards alcohol-related stimuli than patients without craving (P < 0.001, d = 1.093), resulting in opposite approach/avoidance AB according to craving presence/absence. SAUD patients without craving showed a stronger avoidance AB than controls (P = 0.003, d = 0.806). AB did not vary according to cognitive load (P = 0.962, η2 p  = 0.004).

CONCLUSIONS

The direction of alcohol-related attentional bias (approach/avoidance) appears to be determined by patients' subjective craving at testing time and does not function as a stable trait of severe alcohol use disorder. Alcohol-related attentional bias appears to rely on later/controlled attentional stages but is not modulated by the saturation of the reflective/control system.

I spy with my little eye: An eye-tracking study examining adolescents' attention to alcoholic and non-alcoholic beverages in Instagram stories

Social media users are frequently exposed to alcohol images on Instagram, which in turn influences their own alcohol behaviors. Yet, it is unclear what factors drive attention to alcohol cues. In an eye-tracking study (N = 108; Mage = 16.54), we examined adolescents' attention to Instagram Stories depending on: (a) the type of beverage depicted (beer vs water), (b) the character-product interaction portrayed (CPI: peers in images shown consuming [high CPI] vs holding beverages [low CPI]) and, (c) participant's own susceptibility (high vs low-risk alcohol drinker). Our results illustrated that adolescents allocated an equal amount of attention to beer and water depicted in Instagram images. Furthermore, they devoted more attention to Instagram images wherein peers were shown consuming water and beer (high CPI) compared to those wherein peers were holding these beverages (low CPI). Surprisingly, high-risk alcohol drinkers were more responsive to both beer and water cues than low-risk drinkers. This was particularly the case for Instagram images with high CPI. These findings have implications for how health cues on Instagram are attended to and processed.

Suppressive Control of Incentive Salience in Real-World Human Vision

Reward-related activity in the dopaminergic midbrain is thought to guide animal behavior, in part by boosting the perceptual and attentional processing of reward-predictive environmental stimuli. In line with this incentive salience hypothesis, studies of human visual search have shown that simple synthetic stimuli, such as lines, shapes, or Gabor patches, capture attention to their location when they are characterized by reward-associated visual features, such as color. In the real world, however, we commonly search for members of a category of visually heterogeneous objects, such as people, cars, or trees, where category examples do not share low-level features. Is attention captured to examples of a reward-associated real-world object category? Here, we have human participants search for targets in photographs of city and landscapes that contain task-irrelevant examples of a reward-associated category. We use the temporal precision of EEG machine learning and ERPs to show that these distractors acquire incentive salience and draw attention, but do not capture it. Instead, we find evidence of rapid, stimulus-triggered attentional suppression, such that the neural encoding of these objects is degraded relative to neutral objects. Humans appear able to suppress the incentive salience of reward-associated objects when they know these objects will be irrelevant, supporting the rapid deployment of attention to other objects that might be more useful. Incentive salience is thought to underlie key behaviors in eating disorders and addiction, among other conditions, and the kind of suppression identified here likely plays a role in mediating the attentional biases that emerge in these circumstances.Significance Statement Like other animals, humans are prone to notice and interact with environmental objects that have proven rewarding in earlier experience. However, it is common that such objects have no immediate strategic use and are therefore distracting. Do these reward-associated real-world objects capture our attention, despite our strategic efforts otherwise? Or are we able to strategically control the impulse to notice them? Here we use machine learning classification of human electrical brain activity to show that we can establish strategic control over the salience of naturalistic reward-associated objects. These objects draw our attention, but do not necessarily capture it, and this kind of control may play an important role in mediating conditions like eating disorder and addiction.

Comparing cigarette-cue attentional bias between people with HIV/AIDS and people with opioid use disorder who smoke

Background

Special populations like people living with HIV/AIDS (PLWHA) and people with opioid use disorder (OUD) smoke tobacco cigarettes at rates three to four times greater than the general population. Patients with tobacco use disorder exhibit attentional bias (AB) for cigarette cues. Eye tracking can quantify this bias by measuring fixation time (FT) on cigarette and matched neutral cues, to calculate an AB score. Although previous studies have measured this bias in people who smoke without any other comorbid conditions, no study, to our knowledge, has measured or compared this bias in special populations.

Methods

We performed exploratory analyses on eye tracking data collected in two separate randomized clinical trials (RCTs) (NCT05049460, NCT05295953). We compared FT and cigarette-cue AB score (measured by subtracting FT on neutral cues from FT on cigarette cues) between PLWHA and people with OUD who smoke, using a visual probe task and Tobii Pro Fusion eye tracker. We used two cigarette cue types, one encompassing people smoking cigarettes and the other consisting of cigarette paraphernalia. We used two cue presentation times, 1000 and 2000 milliseconds (ms).

Results

Cues of people smoking cigarettes elicited greater AB than cues of cigarette paraphernalia across both subject groups when cues were presented for 2000 ms, but not 1000 ms. PLWHA who smoke exhibited greater AB for cues of people smoking cigarettes than cigarette paraphernalia when presented for 2000 ms compared to people with OUD who smoke.

Conclusion

We use cigarette-cue AB to quantify craving and cigarette consumption in two populations smoking at elevated rates. The addition of social cues potentiates cigarette cue AB, based on cue type and stimulus presentation time. Understanding the neurobiology of this relationship can help design novel smoking cessation treatments that target AB and prevent relapse in these populations with suboptimal response to smoking cessation treatments.

Trial registration

Clinical trials that provided the data for post hoc analyses are NCT05049460 and NCT05295953.

Neurocognitive predictors of addiction-related outcomes: A systematic review of longitudinal studies

It is well-established that addiction is typically associated with a distinct pattern of neurocognitive functioning with a consensus that it is typified by impaired top-down executive control and aberrant risk-reward processing. Despite a consensus that neurocognition plays an important role in characterizing and maintaining addictive disorders, there is a lack of systematic, bottom-up synthesis of quantitative evidence showing that neurocognition predicts addictive behaviors, and which neurocognitive constructs have the best predictive validity. This systematic review aimed to assess whether cognitive control and risk-reward processes as defined by the Research Domain Criteria (RDoC) predict the development and maintenance of addictive behaviors specifically, consumption, severity, and relapse. The findings from this review expose the substantial lack of evidence for neurocognition predicting addiction outcomes. However, there is evidence that suggests reward-related neurocognitive processes may be important for the detection of early risk for addiction, as well as a potentially viable target for designing novel, more effective interventions.

Integrating cognitive bias modification for pain and opioid cues into medication for opioid use disorder clinical care: Feasibility, acceptability, and preliminary results

BACKGROUND

Despite high co-occurrence, chronic pain is often unaddressed in treatment for opioid use disorder (OUD) and little is known about mechanisms that may underlie associations between pain and opioid use. Using an attentional bias (AB) task with both pain and opioid cues, we evaluated a cognitive bias modification (CBM) task administered during regularly scheduled medications for OUD (mOUD) dosing visits. The current study evaluated the feasibility, acceptability, and preliminary efficacy of the CBM task. Outcomes for AB tasks used traditional mean-based score and trial-level bias scores (TLBS).

METHODS

In a double-blind, randomized controlled trial, 28 individuals with OUD and chronic pain engaged in mOUD were randomized to either CBM or an AB control condition and completed up to three tasks per week for four weeks. Standard AB task was completed at baseline and post-treatment. Participants completed feasibility and acceptability measures, and preliminary efficacy (i.e., change in AB) was assessed using ANOVA models.

RESULTS

Participants attended 83.3% of scheduled sessions and generally reported the task was enjoyable, credible, and easy to complete. Preliminary results demonstrated a condition by time interaction highlighting a reduction in AB in the CBM group but not the control group in opioid TLBS variability (F[1,26]=5.01, p = .034) and pain TLBS towards (F[1,26]=6.42, p = .018) and pain TLBS variability (F[1,26]=5.24, p = .03).

CONCLUSIONS

The current study supports integrating brief, computer-based tasks designed to reduce AB into mOUD clinical care. The preliminary results suggest that TLBS outcomes may be more sensitive to capture changes in AB; however, larger studies are required.

Tell me how you feel, I will tell you what you look at: Impact of mood and craving on alcohol attentional bias in binge drinking

BACKGROUND

Alcohol-related attentional bias (AB) is thought to play a key role in the emergence and maintenance of excessive alcohol use. Recent models suggest that AB, classically considered as a permanent feature in alcohol use disorders, is rather modulated by temporary motivational states.

AIMS

We explored the influence of current mood and craving on AB in binge drinking, through a mood induction procedure combined with eye-tracking measures of AB.

METHODS

In Experiment 1, we measured AB (visual probe task with eye-tracking measures) among binge drinkers (n = 48) and light drinkers (n = 32) following positive, negative and neutral mood inductions. Participants reported subjective craving and mood before/after induction. In Experiment 2, we measured AB among the same binge drinkers compared with 29 moderate drinkers following alcohol-related negative, non-alcohol-related negative and neutral mood inductions.

RESULTS

In Experiment 1, induced negative mood and group positively predicted subjective craving, which was positively associated with AB. We found no effect of induced positive mood nor a direct mood-AB association. In Experiment 2, the relationships AB presented with both induced negative mood and group were again mediated by craving. Inducing alcohol-related negative mood did not modify the mood-craving association.

CONCLUSIONS

Alcohol-related AB is not a stable binge drinking characteristic but rather varies according to transient motivational (i.e., craving) and emotional (i.e., negative mood) states. This study provides important insights to better understand AB in subclinical populations and emphasizes the importance of considering motivational and affective states as intercorrelated, to offer multiple ways to reduce excessive alcohol use.

The role of attention in decision-making under risk in gambling disorder: An eye-tracking study

Gambling disorder (GD) is a behavioural addiction characterized by impairments in decision-making, favouring risk- and reward-prone choices. One explanatory factor for this behaviour is a deviation in attentional processes, as increasing evidence indicates that GD patients show an attentional bias toward gambling stimuli. However, previous attentional studies have not directly investigated attention during risky decision-making. 26 patients with GD and 29 healthy matched controls (HC) completed a mixed gambles task combined with eye-tracking to investigate attentional biases for potential gains versus losses during decision-making under risk. Results indicate that compared to HC, GD patients gambled more and were less loss averse. GD patients did not show a direct attentional bias towards gains (or relative to losses). Using a recent (neuro)economics model that considers average attention and trial-wise deviations in average attention, we conducted fine-grained exploratory analyses of the attentional data. Results indicate that the average attention for gains in GD patients moderated the effect of gain value on gambling choices, whereas this was not the case for HC. GD patients with high average attention for gains started gambling at less high gain values. A similar trend-level effect was found for losses, where GD patients with high average attention for losses stopped gambling at lower loss values. This study gives more insight into how attentional processes in GD play a role in gambling behaviour, which could have implications for the development of future treatments focusing on attentional training or for the development of interventions that increase the salience of losses.

Impulsivity Predicts Relapse—but Not Dropout—in Outpatients with SUD: a Longitudinal Study

The objective of this study was to compare performance on a comprehensive impulsivity battery of SUD outpatients who dropout versus those who do not dropout and of abstainers versus relapsers at 3 and 12 months of treatment follow-up. Impulsivity was measured at the start of treatment and adherence and relapse at 3 and 12 months. The participants are 115 outpatients with SUD. Motor impulsivity (Affective Go/No Go), attentional impulsivity (Stroop), delay discounting (Monetary Choice Questionnaire; MCQ), and decision making (Iowa Gambling Task; IGT) were assessed. Impulsivity was not associated with dropout. There were no relationships between treatment outcomes and the MCQ and IGT. Stroop and affective Go-No Go were associated with relapse at 3 and 12 months. Affective motor disinhibition and cognitive disinhibition predict relapse in outpatients. No cognitive aspect of impulsiveness is related to dropout.

The who and how of attentional bias in cannabis users: associations with use severity, craving and interference control

AIMS

Cognitive and motivational processes are thought to underlie cannabis use disorder (CUD), but research assessing how cognitive processes [e.g. interference control (IC)] interact with implicit [e.g. attentional bias (AB)] and explicit motivation (i.e. craving) is lacking. We assessed the presence of AB in cannabis users with varying use severity and tested models of moderation, mediation and moderated mediation to assess how AB, craving and IC interact in their association with measures of cannabis use.

DESIGN

A cross-sectional study design was used.

SETTING AND PARTICIPANTS

Eight studies performed by our laboratory in the Netherlands including never-sporadic, occasional (≤ 1/month) and regular cannabis users (≥ 2/week), and individuals in treatment for CUD were combined (n = 560; 71% male).

MEASUREMENTS

Studies included a classic Stroop task (IC), a cannabis Stroop task (AB) and measures of session-induced and average session craving. Both heaviness of cannabis use (grams/week) and severity of use related problems were included.

FINDINGS

Only those in treatment for CUD showed an AB to cannabis (P = 0.019) and group differences were only observed when comparing CUD with never-sporadic users (P = 0.007). In occasional and regular users, IC was negatively associated with heaviness (β = 0.015, P < 0.001), but not severity of use. Average session craving (exploratory), but not session-induced craving (confirmatory), mediated this association between AB and heaviness (β = 0.050, P = 0.011) as well as severity of use (β = 0.083, P = 0.009); higher AB was associated with heavier use and more severe problems through increased craving.

CONCLUSIONS

Attentional bias only appears to be present in cannabis users with the most severe problems and craving appears to mediate the association between attentional bias and both heaviness and severity of use in occasional and regular users. The association of interference control with heaviness but not severity of use may point to subacute intoxication effects of cannabis use on interference control.

[Comparative Harm/Benefit Analysis of Various Psychotropic Substances from the Perspective of German Drug Users and Addiction Medicine Experts - A Contribution to Psychoeducation of Substance-Addicted Individuals and Restriction/Legalization Debates]

BACKGROUND

To date, we cannot find any current international comparative study on the assessment of a benefit/harm profile of various licit and illicit psychoactive substances conducted by adult drug users and addiction experts as well. Particularly, there is no study from the German-speaking area of Western Europe.

METHODS

In addition to the data already published by 101 German addiction medicine experts (published in this journal, [1]), we carried out interviews using a structured questionnaire with 100 German substance dependent users, residing in acute and rehabilitation clinical setting, to evaluate 34 psychoactive substances regarding their health and social harm potential for users and others as well as their potential benefit.

RESULTS

Both, users and experts estimated traditional illicit drugs, such as heroin, crack/cocaine and methamphetamine, to be particularly harmful. Synthetic cannabinoids, alcohol and benzodiazepines were in the upper midfield, cannabis and psychotropic mushrooms in the lower midfield, and gabapentinoids at the bottom of the harm rankings of both, users and experts. In comparison with the experts, the users estimated methadone and benzodiazepines to be significantly more harmful. In the benefit analysis, users rated traditional illicit drugs including cannabis and psychotropic mushrooms as well as nicotine as significantly more useful than the experts. In contrast to the experts (traditional illicit drugs), the users did not assess any substance as very harmful and very useless at the same time. Only a few users reported to have experiences with opioid analgesics which, however, did not differ between the users´ and experts´ harm/benefit-assessments. Neither users nor experts predicted cannabis-legalization to change the overall risk potential of cannabis. Specific cognitive valuation biases seemed to be prominent in both groups.

CONCLUSION

This study presents first harm/benefit assessments of psychotropic substances from the perspective of German addiction medicine experts and drug users. The results can be valuable to the psychoeducation of substance-addicted individuals and to current restriction or legalization debates.

Differences between users' and addiction medicine experts' harm and benefit assessments of licit and illicit psychoactive drugs: Input for psychoeducation and legalization/restriction debates

Background

There is a lack of benefit/harm assessments of illicit and licit psychoactive substances performed by substance-dependent users in comparison to addiction medicine experts.

Methods

We extended the analyses of substance harm/benefit assessments of German addiction medicine experts (N = 101), in parts reported recently in this journal [doi.org/10.3389/fpsyt.2020.59219], by the perspectives of substance-addicted persons. The same questionnaire as used for the abovementioned "experts-study" was handed out to inpatient detoxification or rehab treatment seeking German substance-dependent adults (N = 117) for a subsequent structured interview about harms and benefits of 33 new and traditional psychoactive substances comprising also prescription drugs.

Results and discussion

Both, users and experts, ranked the traditional illicit psychoactive substances heroin, cocaine and amphetamines within the top overall harm level group. Synthetic cannabinoids, alcohol and benzodiazepine were in a subordinate top-harm level position. Both cohorts also ranked methadone, nicotine and cannabis within the midrange and buprenorphine as well as psychotropic mushrooms within the lowest harm level positions. Experiences with prescription drugs (including opioidergic analgesics and gabapentinoids), cathinones, GHB, methamphetamine and methylphenidate was not prevalent in our user population. The same applied to barbiturates, propofol, kratom, ayahuasca with nearly zero assessments for each substance. The most user-experiences (>50% per assessed substance) were reported with nicotine, cannabis, alcohol, cocaine, heroin, amphetamine and methadone (core group). The user's overall harm ratings in terms of these psychoactive substances were similar to those of the experts with the exception of the methadone assessment which was rated by the experts to be significantly less harmful if compared with the users' estimation (supposed "treatment bias" of experts). The users' benefit ratings for the traditional illicit psychoactive substances, cannabis as well as for nicotine were significantly more positive in comparison to those of the experts (supposed "attraction bias" of users). Both, experts and users, ranked the harms arising from the use of alcohol or benzodiazepines (usually unregulated substances) higher than the harms caused by the use of methadone, cannabis or psychotropic mushrooms (regulated by most Western narcotic acts). Users attributed the most benefits to buprenorphine, methadone and cannabis. This might reflect a main limitation of the study as the data are from an user population comprising over 50% patients who sought detoxification-treatment of opiates where methadone and buprenorphine are usual transient medications (supposed "selection bias").

Conclusion

This study addressed current trends of psychoactive substance abuse (e.g., synthetic cannabinoids, prescription drugs) and provides from both perspectives (that of the user and that of the addiction medicine experts) robust harm/benefit evaluations at least of a core group of psychoactive substances (traditional illicit psychoactive substances, cannabis, methadone, alcohol and nicotine). The results of this study can be valuable to the psychoeducation of substance-addicted individuals and to current restriction/legalization debates, especially in the Western-EU.

An experimental test of integrating imagery with approach bias modification for alcohol: A cautionary tale

OBJECTIVES

In terms of dual process models, behaviour can be conceived of as the outcome of an interplay between reflective, top-down and impulsive, bottom-up processes. Behaviour change interventions may benefit from targeting both types of processes in a coherent way. One approach to this, in the context of reducing hazardous drinking, is to combine imagery involving real-life situations involving alcohol with the simple actions involved in Approach Bias Modification (ApBM), a form of Cognitive Bias Modification.

DESIGN

We developed and tested a version of this Imagery-enhanced Approach Bias Modification (IApBM) in an experimental design, with two independent factors: imagery versus control and ApBM versus control training components (N = 139).

METHODS

An effect of integrating the training factors was hypothesized on the alcohol-approach bias of an alcohol Approach-Avoidance Task. Further exploratory analyses were performed for the bias on alcohol-related Single Attribute Implicit Association Tests and on alcohol-related questionnaires. Finally, the psychometric properties of an imagery interference effect during training were explored.

RESULTS

Results showed no benefit of the training and in fact suggested a negative interaction in which combining the training components appeared to block reductions in craving effected by each in isolation. The reliability of the imagery-related interference effect was high and the effect was correlated with alcohol-related scales.

CONCLUSIONS

In conclusion, it appears that interference between training components decreases their individual effects when combining imagery and ApBM in the current way. The imagery-related interference effects that could be measured during training conditions may be useful as an implicit measure of automatic processes underlying hazardous drinking.

Differences in attentional bias to smoking-related, affective, and sensation-seeking cues between smokers and non-smokers: an eye-tracking study

RATIONALE

One of the behavioural features of tobacco use disorder is the presence of attentional bias (AB) to smoking-related stimuli. However, much of the research investigating these associations have been limited to the use of reaction-based indices.

OBJECTIVES

We aimed to investigate differences in AB to smoking, affective, and sensation-seeking cues in smokers and non-smokers using novel, free-viewing, eye-tracking technology. Secondary aims included investigating impulsivity-by-group interaction effects on AB to sensation-seeking cues.

METHODS

Participants were either otherwise-healthy smokers of at least 8 cigarettes per day or otherwise-healthy non-smokers (< 100 cigarettes in their lifetime and no smoking in the past year). AB was measured using a free-viewing, eye-tracking system. Participants were presented a series of slides divided into 3 themes: smoking, affective, and sensation-seeking. Each slide contained 4 images (1 theme-related, 1 neutral, 2 competitive). Primary outcome measure was the difference in the proportion of time spent viewing the theme-related cue to neutral cue. Impulsivity was measured using a monetary delayed discounting task.

RESULTS

The sample consisted of 50 smokers (41 ± 12 years old) and 50 age- and sex-matched non-smokers (40 ± 14 years old). Smokers spent over 2 times longer looking at smoking-related images than non-smokers (F = 25.50, p < 0.001). As well, greater impulsivity was significantly associated with increased AB to sensation-seeking cues (R² = 0.059, F = 2.98, p = 0.04) in smokers but not non-smokers. No differences were found on AB to affective cues.

CONCLUSION

The eye-tracking procedure is a sensitive tool for assessing AB in smokers compared to non-smokers to both smoking and sensation-seeking cues.

Pupil size as a robust marker of attentional bias toward nicotine-related stimuli in smokers

Spatial attention can be magnetically attracted by behaviorally salient stimuli. This phenomenon occasionally conflicts with behavioral goals, leading to maladaptive consequences, as in the case of addiction, in which attentional biases have been described and linked with clinically meaningful variables, such as craving level or dependence intensity. Here, we sought to probe the markers of attentional priority in smokers through eye-tracking measures, by leveraging the established link between eye movements and spatial attention. We were particularly interested in potential markers related to pupil size, because pupil diameter reflects a range of autonomic, affective, and cognitive/attentional reactions to behaviorally significant stimuli and is a robust marker of appetitive and aversive learning. We found that changes in pupil size to nicotine-related visual stimuli could reliably predict, in cross-validated logistic regression, the smoking status of young smokers (showing pupil constriction) better than more traditional proxy measures. The possibility that pupil constriction may reflect a bias toward central vision, for example, attentional capture, is discussed in terms of sensory tuning with respect to nicotine-related stimuli. Pupil size was more sensitive at lower nicotine dependence levels, and at increased abstinence time (though these two variables were collinear). We conclude that pupillometry can provide a robust marker for attentional priority computation and useful indications regarding motivational states and individual attitudes toward conditioned stimuli.

Biomarkers of Relapse in Cocaine Use Disorder: A Narrative Review

Introduction: Cocaine use disorder is a chronic disease with severe consequences and a high relapse rate. There is a critical need to explore the factors influencing relapse in order to achieve more efficient treatment outcomes. Furthermore, there is a great need for easy-to-measure, repeatable, and valid biomarkers that can predict treatment response or relapse. Methods: We reviewed the available literature on the Pubmed database concerning the biomarkers associated with relapse in CUD, including central nervous system-derived, genetic, immune, oxidative stress, and “other” biomarkers. Results: Fifty-one articles were included in our analysis. Twenty-five imaging brain anatomic and function assessment studies, mostly using fMRI, examined the role of several structures such as the striatum activity in abstinence prediction. There were fewer studies assessing the use of neuropsychological factors, neurotrophins, or genetic/genomic factors, immune system, or oxidative stress measures to predict abstinence. Conclusion: Several biomarkers have been shown to have predictive value. Prospective studies using combined multimodal assessments are now warranted.

Attentional bias in alcohol drinkers: A systematic review of its link with consumption variables

In severe alcohol use disorder (SAUD), attentional bias refers to the preferential allocation of attentional resources toward alcohol-related cues. Dominant models consider that this bias plays a key role in the emergence and maintenance of SAUD. We evaluate the available experimental support for this assumption through a systematic literature review, providing a critical synthesis of studies exploring the links between alcohol consumption and attentional bias. Using PRISMA guidelines, we explored three databases (PsycINFO, PubMed, Scopus) and extracted 95 papers. We assessed their methodological quality and categorized them based on the population targeted, namely patients with SAUD or subclinical populations with various drinking patterns. We also classified papers according to the measures used (i.e., behavioral or eye-tracking measures). Overall, subclinical populations present an alcohol-related bias, but many studies in SAUD did not find such bias, nor approach/avoidance patterns. Moreover, attentional bias fluctuates alongside motivational states rather than according to alcohol use severity, which questions its stability. We provide recommendations to develop further theoretical knowledge and overcome methodological shortcomings.

Attentional Bias to Alcohol Information: a Novel Dual-Probe Task

BACKGROUND

Even when motivated to consume less alcohol, attempts to do so are not always successful. Attentional bias to positive and negative alcohol-related information may play a role in shaping unintended drinking behaviour. The present exploratory study adapted a novel attentional bias task, to test whether selective attention to positive relative to negative information about alcohol consumption predicts mismatch between alcohol consumption intention and alcohol consumption behaviour.

METHOD

Thirty-five university students attempting to reduce their alcohol consumption participated in the study. Participants completed a novel attentional bias assessment task where two positive and negative audio-visual messages about alcohol consumption were simultaneously presented. At random intervals during these messages, two different probes were briefly and simultaneously presented, so that only one could be detected. Attention to positive vs. negative messages was inferred from the location of the probe recorded by the participant. Alcohol consumption in relation to participants' goals was measured using a real-time diary over the subsequent 7 days.

RESULTS

An attentional bias towards positive (relative to negative) messages about alcohol consumption predicted the degree to which participants consumed more alcohol than planned, but did not predict alcohol consumption itself.

CONCLUSION

This is the first study to our knowledge that has investigated the relationship between biased attention to alcohol-related information and variation in the success of intended reduction in alcohol consumption, and we suggest that it paves the way for further research into the role of attentional biases in health risk behaviours.

Cognitive training in recently-abstinent individuals with alcohol use disorder improves emotional stroop performance: Evidence from a randomized pilot trial

BACKGROUND

Cognitive training interventions appear capable of improving alcohol-associated neurobehavioral deficits in recently detoxified individuals. However, efficacy remains incompletely characterized in alcohol use disorder (AUD) and available data address only non-affective cognitive outcomes; enhancement of social cognition remains uninvestigated. We utilized a training paradigm in which successfully ignoring emotionally-valent stimuli benefitted task performance. We hypothesized trained individuals would display improvements in an affective inhibitory control task, and that individuals trained with high valence (relative to neutral) stimuli would evince greater improvement.

METHODS

42 recently detoxified inpatients with AUD were assigned to one of three groups (Emotional Training, Neutral Training, or Treatment as Usual [TAU]). Training consisted of two computerized working memory tasks (dual-modality n-back task; attend/ignore task) which included task-irrelevant stimuli (emotional vs. neutral). Post-training performance efficiency (indexing speed-accuracy tradeoffs) in an emotional Stroop task was the outcome of interest.

RESULTS

Significant group by time interactions were detected for emotional Stroop performance, supporting our hypothesis that trained groups would exhibit greater improvement than TAU controls (F[2,39]=8.61, p < .01). Additionally, the emotional training condition appeared to result in greater improvement relative to neutral training (F[1,26]=4.98, p < .01).

CONCLUSION

Results are consistent with current literature suggesting the potential of training to enhance cognitive recovery in early abstinence. Findings inform the development of training protocols, suggesting integration of task-irrelevant distractor stimuli in training may enhance cognitive control outcomes. Further, they expand the relevant domains for application of training approaches, providing novel evidence that among individuals with AUD, training-associated benefits may extend to social cognitive domains.

Changes in Drug-Related Implicit Associations during Substance Use Disorder Treatment: The Role of the Therapeutic Context

BACKGROUND

Implicit cognition has been linked to relapse in substance use disorder (SUD). Studies on attentional bias have found different outcomes related to the therapeutic context, finding an association with relapse in inpatients but not in outpatients. There are no similar studies that use associations in semantic memory as a measure of implicit cognition.

OBJECTIVES

(i) to analyze the relationship between a measure of associations in semantic memory and relapse in inpatients and outpatients; (ii) to compare the evolution of these associations between inpatients and outpatients after 3 months of treatment.

METHODS

Eighty nine outpatients and 94 inpatients with SUD for cocaine and alcohol participated in this study. We employed a longitudinal design with a baseline evaluation and follow-up after three months, using the Word Association Task for Drug Use Disorder (WAT-DUD).

RESULTS

The choice of drug-related words predicted relapse in cocaine (odds ratio = 1.97, z = 2.01, p = .045) and alcohol-cocaine (odds ratio = 2.39, z = 2.55, p = .011) use. Follow-up at 3 months revealed a reduction in the choice of drug-related words in inpatients (Z = 2.031, p = .042).

CONCLUSIONS

A greater choice of drug-associated words in the presence of ambiguous images was related to relapse in inpatients but not in outpatients. The inpatients group showed a reduction in the semantic association with drugs during the first three months of treatment.

Raising the bar: improving methodological rigour in cognitive alcohol research

BACKGROUND AND AIMS

A range of experimental paradigms claim to measure the cognitive processes underpinning alcohol use, suggesting that heightened attentional bias, greater approach tendencies and reduced cue-specific inhibitory control are important drivers of consumption. This paper identifies methodological shortcomings within this broad domain of research and exemplifies them in studies focused specifically on alcohol-related attentional bias.

ARGUMENT AND ANALYSIS

We highlight five main methodological issues: (i) the use of inappropriately matched control stimuli; (ii) opacity of stimulus selection and validation procedures; (iii) a credence in noisy measures; (iv) a reliance on unreliable tasks; and (v) variability in design and analysis. This is evidenced through a review of alcohol-related attentional bias (64 empirical articles, 68 tasks), which reveals the following: only 53% of tasks use appropriately matched control stimuli; as few as 38% report their stimulus selection and 19% their validation procedures; less than 28% used indices capable of disambiguating attentional processes; 22% assess reliability; and under 2% of studies were pre-registered.

CONCLUSIONS

Well-matched and validated experimental stimuli, the development of reliable cognitive tasks and explicit assessment of their psychometric properties, and careful consideration of behavioural indices and their analysis will improve the methodological rigour of cognitive alcohol research. Open science principles can facilitate replication and reproducibility in alcohol research.

The predictive value of evaluative bias, attentional bias, approach bias, and self-regulatory control in soft drink consumption

Global consumption of soft drinks has increased rapidly over the past 50 years, making this a major public health problem. Guided by dual-process models, the present study aimed to provide a comprehensive investigation of the roles of cognitive biases (evaluative, attentional, and approach biases) and self-regulatory control in soft drink consumption and choice. Participants were 128 undergraduate students (17-25 years). They completed computer-based measures of the three biases (Implicit Association Task, Dot Probe Task, and Approach Avoidance Task) and self-regulatory control (Go/no-go Task). Soft drink consumption and choice were measured using a taste test and a take home beverage choice task, respectively. Evaluative bias for soft drink cues was positively associated with the amount of soft drink consumed. Self-regulatory control was negatively correlated with amount of soft drink consumed, but only for men. There was no interaction between cognitive biases and self-regulatory control in predicting soft drink consumption or choice. Nonetheless, the results support the application of dual-process models to soft drink consumption in that automatic (evaluative bias) and controlled processes (self-regulatory control) each predicted amount of soft drink consumed, albeit independently and only for certain individuals. Future research should extend these findings to habitual soft drink consumers and to individuals who actively wish to limit their soft drink intake.

Acute impact of self-guided mental imagery on craving in cocaine use disorder: a mixed-methods analysis of a randomized controlled trial

Mental imagery manipulations are used to treat several psychological disorders, but their utility in treating cocaine use disorder (CUD) is unknown. Using prompted re-experiences and simulations with contrasting valence, we assessed the acute impact of a deliberate mental imagery task on cocaine craving.

DESIGN

A quantitative-qualitative 'mixed-methods' analysis of data collected for a randomized controlled trial that was stopped prematurely.

SETTING

UK National Health Service addictions treatment clinic and outpatient clinical research facility (laboratory).

PARTICIPANTS

Adults with CUD. The original target sample was 120. All participants enrolled at the point the original trial was stopped were included (38 enrolled, 31 completed study).

INTERVENTIONS

Personalized (3-minute) cue-exposure (handling cocaine paraphernalia and watching video of drug preparation), immediately followed by a single 5-minute, audio-recorded, self-guided and verbally described imagery task with random assignment to one of four conditions: two mental imagery memory re-experiences (positive image before initiation to cocaine use or a negative image of a 'worst time' adverse cocaine use episode) or two future simulations (positive theme of recovery from CUD or negative theme of worsened CUD).

MEASUREMENTS

Task transcripts were rated for imagery detail using five dimensions using a six-point scale of imagery detail (ID) (total score = 0-25) and thematically coded. The outcome measure was cocaine craving using the Craving Experiences Questionnaire-strengths version (CEQ-S11; score = 0-110) reported at baseline, arrival at the laboratory, and immediately after the cue-exposure and mental imagery tasks.

FINDINGS

A mixed-effects, longitudinal, restricted linear regression, with the past-positive imagery condition as referent, showed main effects of reduced craving after the imagery task (b = -29.2, 95% confidence interval (CI) = -45.3 to -13.1, P-value < 0.001) and increased craving for the future-negative task (b = 14.2, 95% CI = 0.1-28.4, P-value 0.049). There was a future-negative task by post-imagery craving interaction (b = 28.1, 95% CI = 0.1-56.1, P-value 0.049). A theory-driven, deductive/inductive qualitative analysis of the transcripts revealed six major themes: sensory characteristics, CUD vicious cycle, self-care, emotions and appraisals, social role and CUD recovery. Positively themed simulations included interpersonal connections and rewarding activity; negative images included personal adversity, with appraisals of self-criticism and hopelessness. Transcripts with more imagery detail were not associated with significantly greater reductions in craving in the positive or negative imagery task (r = -0.32, 95% CI = -0.69 to 0.13 and r = 0.06, 95% CI = -0.58 to 0.53, respectively).

CONCLUSION

In people with cocaine use disorder, after cue-exposure, a self-guided imagery task with positive themes reduced craving, whereas mental imagery simulating worsened cocaine use disorder did not appear to.

The Influence of Smoking Motivation on the Associations Among Cigarette Craving, Attentional Bias to Smoking Cues, and Smoking Behavior

INTRODUCTION

Theory and data suggest that attentional bias (AB) to drug-related cues should be associated with craving when smoking motivation is high, and that AB should be predictive of drug use when immediate use is possible. The current study is the first to test these propositions in smokers in a controlled laboratory environment.

AIMS AND METHODS

Ninety daily smokers were randomly assigned to a high smoking motivation (nicotine-deprived and/or smoking cue exposure) or low smoking motivation (non-deprived and/or control cue exposure) condition. Participants engaged in an AB task in which they viewed smoking and matched control pictures while their eye movements were continuously monitored. Participants were then given the option to smoke, and latency to first puff and number of puffs were coded.

RESULTS

High motivation smokers had significantly higher urges to smoke (p < .001) and shorter latencies to smoke (p = .001) than low motivation smokers, but AB measures (ie, dwell time and initial fixation bias scores) and number of puffs did not differ across groups (ps > .45). As predicted, the association between dwell time bias scores and urge to smoke was stronger in the high (r = .47) than low (r = .18) smoking motivation condition, but this difference failed to reach significance (p = .068). Contrary to predictions, neither AB measure was significantly associated with smoking behavior (SB). Internal reliability was excellent for dwell time bias scores (alpha = .90) but very low for initial fixation bias scores (alpha = .20).

CONCLUSIONS

Maintenance of attention on drug-related cues may be a valid index of incentive motivation. Importantly, however, these dwell time bias scores were not predictive of actual SB.

IMPLICATIONS

This study tested key predictions made by theoretical accounts of addiction that emphasize AB to drug-related cues as fundamental components of the development and maintenance of drug use. Namely, this is the first experimental study in smokers to test whether AB to smoking-related cues is associated with craving when smoking motivation is high and whether AB predicts SB assessed immediately after the AB task. As predicted, the association between AB and craving was stronger in smokers randomly assigned to a high rather than a low smoking motivation condition. Contrary to predictions, AB did not predict SB.

Alcohol-related attentional biases in recently detoxified inpatients with severe alcohol use disorder: an eye-tracking approach

BACKGROUND

Dominant theoretical models consider that attentional biases (AB) towards alcohol-related stimuli play a key role in the development and maintenance of alcohol use disorder (AUD). Their assessment has however showed high inconsistencies and has been mostly based on unreliable behavioral measures. This study evaluated the presence and extent of alcohol-related AB in recently detoxified inpatients with severe AUD by combining the visual probe task (VPT) paradigm with eye-tracking measures, known to improve the VPT reliability in subclinical populations.

METHODS

We recruited 24 patients and 27 matched healthy controls. They performed the VPT (measuring reaction time when processing visual targets preceded by alcoholic and matched non-alcoholic pictures) combined with eye-tracking measures (dwell time, first fixation direction/duration, second fixation direction) during two sessions. Estimates of internal consistency, split-half reliability, and test-retest reliability were measured.

RESULTS

Patients showed shorter dwell time for alcohol cues (p = .004, d=.853) and reduced number of fixations towards alcohol after a first fixation on non-alcohol cues (p = .012, d=.758) compared to controls. These findings suggest the presence of alcohol-related avoidance AB in detoxified patients with severe AUD. The VPT achieved excellent reliability for these eye-tracking measures. Reaction times and first fixation measures did not indicate any AB pattern and showed poor reliability.

CONCLUSIONS

The VPT, when combined with dwell time and second fixation direction, constitutes a reliable method for assessing AB in detoxified patients. It showed the presence of an alcohol-related avoidance bias in this clinical population, in contradiction with the approach bias predicted by theoretical models.

Effectiveness of attentional bias modification training as add-on to regular treatment in alcohol and cannabis use disorder: A multicenter randomized control trial

Background

Attentional bias for substance-relevant cues has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, increase positive treatment outcome and reduce relapse rates. The current study investigated the effectiveness of a newly developed home-delivered, multi-session, internet-based ABM intervention, the Bouncing Image Training Task (BITT), as an add-on to treatment as usual (TAU).

Methods

Participants (N = 169), diagnosed with alcohol or cannabis use disorder, were randomly assigned to one of two conditions: the experimental ABM group (50%; TAU+ABM); or the control group (50%; split in two subgroups the TAU+placebo group and TAU-only group, 25% each). Participants completed baseline, post-test, and 6 and 12 months follow-up measures of substance use and craving allowing to assess long-term treatment success and relapse rates. In addition, attentional bias (both engagement and disengagement), as well as secondary physical and psychological complaints (depression, anxiety, and stress) were assessed.

Results

No significant differences were found between conditions with regard to substance use, craving, relapse rates, attentional bias, or physical and psychological complaints.

Conclusions

The findings may reflect unsuccessful modification of attentional bias, the BITT not targeting the relevant process (engagement vs. disengagement bias), or may relate to the diverse treatment goals of the current sample (i.e., moderation or abstinence). The current findings provide no support for the efficacy of this ABM approach as an add-on to TAU in alcohol or cannabis use disorder. Future studies need to delineate the role of engagement and disengagement bias in the persistence of addiction, and the role of treatment goal in the effectiveness of ABM interventions.

Relationships between Attentional Bias and craving in Alcohol Use Disorder: Role of metacognitions

Researchers have claimed that craving and Attentional Bias (AB) towards alcohol-related cues can be explained by a common incentive-salience mechanism. However, the exact relationship between AB and craving is a matter of debate. The aim of this study was to show that metacognitions moderate the effect of AB on craving. A sample of 38 alcohol abusers undergoing post-withdrawal treating in a hospital setting completed the visual Dot Probe Detection Task (DPDT), while both pre- and post-task measures of craving were recorded. Our results confirmed significant effects of both exposure to pictures of alcohol, and metacognitions, on craving; in particular, the interaction Metacognition * DPDT was significant. Although we initially confirmed a significant main effect of AB on craving, it became non-significant when adjusted for inter-subject variance, and metacognitions. The effect of the interaction AB * Metacognition on craving was not significant. Our findings support the hypothesis that craving and AB share variance, but the relationship appears to be spurious, and caused by confounding factors. We discuss these results with reference to the metacognitive model of addiction.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

Initial orientation vs maintenance of attention: Relationship with the severity of dependence and therapeutic outcome in a sample of cocaine use disorder patients

The visual probe paradigm allows for evaluating attentional bias (AB), distinguishing between approach vs avoidance patterns of attention and assessing two different processes when the exposure time to images is manipulated: initial orienting and maintenance of attention. The present study aimed to analyze the predictive capacity of these two processes for substance use disorder severity and therapeutic outcomes of patients with cocaine use disorder in treatment. The sample consisted of 70 outpatients who were starting treatment at a public service. AB was evaluated using a task based on the visual probe (VP) paradigm with images presented under two conditions: 200 ms vs 1000 ms. Cocaine and alcohol use disorder severity, craving, retention in treatment and relapse in consumption were recorded. Cocaine AB in the 1000 ms condition was negatively correlated with the cocaine use disorder severity (r = -0.26), whilst a positive correlation was found between cocaine craving and cocaine AB (r = 0.29). Alcohol use disorder severity negatively correlated with cocaine AB in the 200 ms condition (r = -0.24). Logistic regression analysis revealed that, after controlling for gender, age, and substance use disorder severity, cocaine AB in the 200 ms condition predicted dropout and relapse. Our results suggest that patients who adhere to treatment and remain abstinent tend to show avoidance in the 200 ms condition, with effect sizes of r = 0.29 and 0.30 respectively. The results suggest that training in avoidance strategies could be a valuable way of maintaining adherence and abstinence, as well as improving control of craving.

Attentional Bias in Alcohol and Cannabis Use Disorder Outpatients as Indexed by an Odd-One-Out Visual Search Task: Evidence for Speeded Detection of Substance Cues but Not for Heightened Distraction

Current cognitive models of addiction imply that speeded detection and increased distraction from substance cues might both independently contribute to the persistence of addictive behavior. Speeded detection might lower the threshold for experiencing craving, whereas increased distraction might further increase the probability of entering a bias-craving-bias cycle, thereby lowering the threshold for repeated substance use. This study was designed to examine whether indeed both attentional processes are involved in substance use disorders. Both attentional processes were indexed by an Odd-One-Out visual search task in individuals diagnosed with alcohol use disorder (AUD; n = 63) and cannabis use disorder (CUD; n = 28). To test whether the detection and/or the distraction component are characteristic for AUD and CUD, their indices were compared with matched individuals without these diagnoses (respectively, n = 63 and n = 28). Individuals with CUD showed speeded detection of cannabis cues; the difference in detection between AUD and the comparison group remained inconclusive. Neither the AUD nor the CUD group showed more distraction than the comparison groups. The sample size of the CUD group was relatively small. In addition, participants made relatively many errors in the attentional bias (AB) task, which might have lowered its sensitivity to detect ABs. The current study provided no support for the proposed role of increased distraction in CUD and AUD. The findings did, however, provide support for the view that speeded detection might be involved in CUD. Although a similar trend was evident for AUD, the evidence was weak and remained therefore inconclusive.

A Promising Candidate to Reliably Index Attentional Bias Toward Alcohol Cues-An Adapted Odd-One-Out Visual Search Task

Attentional bias (AB) has been suggested to contribute to the persistence of substance use behavior. However, the empirical evidence for its proposed role in addiction is inconsistent. This might be due to the inability of commonly used measures to differentiate between attentional engagement and attentional disengagement. Attesting to the importance of differentiating between both components of AB, a recent study using the odd-one-out task (OOOT) showed that substance use was differentially related to engagement and disengagement bias. However, the AB measures derived from the OOOT showed insufficient reliability to be used as a solid measure of individual differences. Therefore, the current study aimed to improve the reliability of the AB measures derived from the OOOT by using more distinct contrast stimuli, adding practice trials, increasing the number of trials, and by having participants perform the task in an alcohol-relevant context. We contrasted the original OOOT with the adapted OOOT (i.e., OOOT-adapt) and assessed AB in low- and high-drinking individuals. Participants were 245 undergraduate students who typically tend to drink either low or high amounts of alcohol. In one condition, AB was measured with the original OOOT in a typical laboratory context, whereas in the other condition, AB was measured with the OOOT-adapt in a bar (i.e., alcohol-relevant) context. The OOOT-adapt showed superior internal consistency, especially for the high-drinking group. Further, specifically the OOOT-adapt differentiated between low- and high-drinking participants showing that high drinkers engaged faster with alcohol cues than did low drinkers. Thus, the OOOT-adapt was found to be a promising candidate to reliably index AB in the context of alcohol use. The OOOT-adapt further showed superior criterion validity as it could differentiate between low- and high-drinking individuals, thereby adding to the evidence that AB might be involved in substance use behavior.

A Randomized Controlled Trial of Attentional Control Training for Treating Alcohol Use Disorder

Background: There is consistent evidence that community and clinical samples of individuals with an alcohol use disorder (AUD) have attentional biases toward alcohol cues. The alcohol attentional control training program (AACTP) has shown promise for retraining these biases and decreasing alcohol consumption in community samples of excessive drinkers. However, there is a lack of evidence regarding the effectiveness of ACTP in clinical AUD samples. The main aim of the present study is to investigate whether primary pharmacological and psychological, evidence-based alcohol treatment can be enhanced by the addition of a gamified AACTP smartphone application for patients with an AUD. Design and Methods: The study will be implemented as a randomized controlled trial. A total of 317 consecutively enrolled patients with AUD will be recruited from alcohol outpatient clinics in Denmark. Patients will be randomized to one of three groups upon initiation of primary alcohol treatment: Group A: a gamified AACTP smartphone application + treatment as usual (TAU); Group B: a gamified AACTP sham-control application + TAU; or Group C: only TAU. Treatment outcomes will be assessed at baseline, post-treatment, and at 3- and 6-month follow-ups. Repeated measures MANOVA will be used to compare the trajectories of the groups over time on alcohol attentional bias, alcohol craving, and drinking reductions. It is hypothesized that Group A will achieve better treatment outcomes than either Group B or Group C. Perspectives: Because attentional bias for alcohol cues is proportional to the amount of alcohol consumed, and these biases are not addressed within current evidence-based treatment programs, this study is expected to provide new evidence regarding the effectiveness of the gamified AACTP in a clinical population. Furthermore, due to promising results found using AACTP in community samples of excessive drinkers, there is a high probability that the AACTP treatment in this study will also be effective, thereby allowing AACTP to be readily implemented in clinical settings. Finally, we expect that this study will increase the effectiveness of evidence-based AUD treatment and introduce a new, low-cost gamified treatment targeting patients with an AUD. Overall, this study is likely to have an impact at the scientific, clinical, and societal levels. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05102942?term=NCT05102942&draw=2&rank=1, identifier: NCT05102942.

Acute methylphenidate administration reduces cocaine-cue attentional bias

Mechanistic research on behavioral processes underlying substance use disorder might help identify novel targets for interventions development. Drug-related attentional bias and response inhibition deficits have received a great deal of consideration in substance use research, broadly, and cocaine use research, specifically. Studies investigating pharmacological mechanisms that may ameliorate, or further impair, these behaviors relevant to cocaine use are relatively lacking. This study evaluated the impact of acute administration of methylphenidate, a dopamine-favoring reuptake inhibitor, on both gaze-related cocaine-cue-attentional bias and cocaine-cue related disruptions in response inhibition among individuals with cocaine use disorder. Participants (N = 12; 33% female) completed a within-subject, outpatient, acute dosing study. Two sessions were completed in which methylphenidate (60 mg) or placebo were administered followed by completion of an attentional bias task using eye-tracking technology and neutral-cue and cocaine-cue response inhibition tasks. Subjective and physiological effects were also recorded. Significant cocaine cue attentional bias and response inhibition failures were observed during placebo administration. Acute methylphenidate administration reduced cocaine-cue attentional bias as measured by cocaine-cue gaze fixations (d_z = 1.04; Bayes Factor = 12.37). No statistically significant effects of methylphenidate were observed on response inhibition (Bayes Factors = 0.17-1.04). Methylphenidate produced prototypical subjective and physiological effects. Although the small sample should be considered, these findings indicate acute manipulation of dopaminergic activity reduced cue-related attentional allocation related to cocaine use disorder. Future research evaluating alternative dopaminergic agents and applications within a clinical setting are needed to determine the clinical significance of targeting this neurobehavioral mechanism.

I can't get it off my mind: Attentional bias in former and current cocaine addiction

BACKGROUND

Cocaine addiction is a global health issue with limited therapeutic options and a high relapse rate. Attentional bias towards substance-related cues may be an important factor for relapse. However, it has never been compared in former and current cocaine-dependent patients.

METHODS

Attentional bias towards cocaine-related words was assessed using an emotional Stroop task in cocaine-dependent patients (N = 40), long-term abstinent former cocaine-dependent patients (N = 24; mean abstinence: 2 years) and control subjects (N = 28). Participants had to name the colour of cocaine-related words, neutral words and colour names. We assessed response times using an automatic voice-onset detection method we developed and we measured attentional bias as the difference in response times between cocaine-related and neutral conditions.

RESULTS

There was an overall group effect on attentional bias towards cocaine, but no group effect on the colour Stroop effect. Two-by-two comparison showed a difference in attentional bias between cocaine-dependent patients and controls, whereas long-term abstinent former cocaine-dependent patients were not different from either. Although cocaine-dependent patients showed a significant attentional bias, consistent with the literature, neither long-term abstinent former cocaine-dependent patients nor controls showed a significant attentional bias towards cocaine-related words. We found no link between attentional bias size and either addiction severity or craving.

CONCLUSIONS

Cocaine abstinence was associated with an absence of significant attentional bias towards cocaine-related words, which may be interpreted either as an absence of attentional bias predicting success in maintaining abstinence, or as attentional bias being able to disappear with long-term cocaine abstinence. Further research is needed to distinguish the role of attentional bias in maintaining abstinence.

Eye Tracking Studies Exploring Cognitive and Affective Processes among Alcohol Drinkers: a Systematic Review and Perspectives

Acute alcohol intoxication and alcohol use disorders are characterized by a wide range of psychological and cerebral impairments, which have been widely explored using neuropsychological and neuroscientific techniques. Eye tracking has recently emerged as an innovative tool to renew this exploration, as eye movements offer complementary information on the processes underlying perceptive, attentional, memory or executive abilities. Building on this, the present systematic and critical literature review provides a comprehensive overview of eye tracking studies exploring cognitive and affective processes among alcohol drinkers. Using PRISMA guidelines, 36 papers that measured eye movements among alcohol drinkers were extracted from three databases (PsycINFO, PubMed, Scopus). They were assessed for methodological quality using a standardized procedure, and categorized based on the main cognitive function measured, namely perceptive abilities, attentional bias, executive function, emotion and prevention/intervention. Eye tracking indexes showed that alcohol-related disorders are related to: (1) a stable pattern of basic eye movement impairments, particularly during alcohol intoxication; (2) a robust attentional bias, indexed by increased dwell times for alcohol-related stimuli; (3) a reduced inhibitory control on saccadic movements; (4) an increased pupillary reactivity to visual stimuli, regardless of their emotional content; (5) a limited visual attention to prevention messages. Perspectives for future research are proposed, notably encouraging the exploration of eye movements in severe alcohol use disorders and the establishment of methodological gold standards for eye tracking measures in this field.

Eye tracking of smoking-related stimuli in tobacco use disorder: A proof-of-concept study combining attention bias modification with alpha-transcranial alternating current stimulation

BACKGROUND

Tobacco use disorder (TUD) is characterized by the presence of an attentional bias (AB) towards smoking-related stimuli. We investigated whether combining an AB modification paradigm (ABM) with transcranial alternating current stimulation (tACS) applied over the dorsolateral prefrontal cortex (DLPFC) reduces the AB towards smoking-related stimuli, as well as craving level and impulsive choices.

METHODS

In a sham-controlled, crossover preliminary study, 19 subjects with TUD received two stimulation arms: 1) active tACS (10 Hz, 2 mA, 30 min) combined with ABM and 2) sham tACS combined with ABM, in a randomized order, separated by one week. AB towards smoking cues during passive observation of smoking and neutral cues was assessed with an eye-tracking device and reactions times at a visual-probe task. Craving level was measured with the Questionnaire of Smoking Urges. Impulsive choices were assessed with the delay discounting task.

RESULTS

Active tACS combined with ABM reduced the amount of time spent looking at smoking-related pictures (p = 0.03), prevented the increase of self-reported desire to smoke (p = 0.026), and reduced the proportion of impulsive choices (p = 0.049), compared to sham tACS combined with ABM. No significant effects were reported on other craving dimensions and on AB based on reaction times.

CONCLUSIONS

These preliminary findings suggest that combining tACS with ABM may help smokers who wish to quit by reducing the desire to smoke, attention to smoking-cues, and impulsive decision-making.