Regulation of Craving and Negative Emotion in Alcohol Use Disorder

Psychometric evaluation of the Chinese version of alcohol relapse risk scale (C-ARRS) in patients with alcohol use disorder

Alcohol use disorder (AUD) is recognized as a chronic relapsing disorder. Alcohol Relapse Risk Scale (ARRS), a multidimensionally self-rating scale, was developed initially by the Japanese to assess the risk of alcohol reuse. The study aimed to validate the reliability and factor structure of the Chinese version of the ARRS (C-ARRS) for patients with AUD. A total of 218 patients diagnosed with AUD according to DSM-5 were recruited for self-administering C-ARRS. We assessed the internal consistency of C-ARRS using Cronbach's α coefficients and examined the factor structure through confirmatory factor analysis (CFA). Additionally, we investigated the concurrent validity by correlating C-ARRS with the Visual Analog Scale of Alcohol Craving (VAS), Penn Alcohol Craving Score (PACS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) scores. CFA demonstrated inadequate data fit for the original 32-item C-ARRS, prompting the development of a revised 27-item version consisting of 6 subscales with satisfactory model fit estimates. The 27-item C-ARRS exhibited favorable internal consistency, with Cronbach's α ranging from 0.611 to 0.798, along with adequate factor loadings. The 27-item C-ARRS scores displayed significant correlations with the scores of VAS, PACS, BDI and BAI (p < .001). Our results indicated favorable reliability and factor structure of the 27-item C-ARRS. The significant correlation between the 27-item C-ARRS and clinical measures (such as depression, anxiety, and craving) demonstrates satisfactory concurrent validity. These observations collectively support the feasibility of using 27-item C-ARRS to assess the risk of alcohol relapse in patients with AUD.

Psilocybin-induced changes in neural reactivity to alcohol and emotional cues in patients with alcohol use disorder: an fMRI pilot study

This pilot study investigated psilocybin-induced changes in neural reactivity to alcohol and emotional cues in patients with alcohol use disorder (AUD). Participants were recruited from a phase II, randomized, double-blind, placebo-controlled clinical trial investigating psilocybin-assisted therapy (PAT) for the treatment of AUD (NCT02061293). Eleven adult patients completed task-based blood oxygen dependent functional magnetic resonance imaging (fMRI) approximately 3 days before and 2 days after receiving 25 mg of psilocybin (n = 5) or 50 mg of diphenhydramine (n = 6). Visual alcohol and emotionally valanced (positive, negative, or neutral) stimuli were presented in block design. Across both alcohol and emotional cues, psilocybin increased activity in the medial and lateral prefrontal cortex (PFC) and left caudate, and decreased activity in the insular, motor, temporal, parietal, and occipital cortices, and cerebellum. Unique to negative cues, psilocybin increased supramarginal gyrus activity; unique to positive cues, psilocybin increased right hippocampus activity and decreased left hippocampus activity. Greater PFC and caudate engagement and concomitant insula, motor, and cerebellar disengagement suggests enhanced goal-directed action, improved emotional regulation, and diminished craving. The robust changes in brain activity observed in this pilot study warrant larger neuroimaging studies to elucidate neural mechanisms of PAT.Trial registration: NCT02061293.

Randomized trial of mindfulness- and reappraisal-based regulation of craving training among daily cigarette smokers

OBJECTIVE

Craving predicts smoking, yet existing interventions may not adequately target regulation of craving. We evaluated two versions of regulation of craving-training (ROC-T), a computerized intervention with intensive practice of strategies when exposed to smoking-related images.

METHOD

Ninety-two nicotine-dependent daily smokers were randomized to mindfulness-based therapy (MBT) ROC-T focusing on mindful acceptance, and cognitive behavioral therapy (CBT) ROC-T focusing on reappraisal or no intervention control. The ROC task was administered pre- and postintervention to assess changes in cue-induced craving and mindfulness- and reappraisal-based regulation of craving.

RESULTS

MBT and CBT-versus control-showed significantly greater reductions in smoking during the intervention phase (baseline to Week 4), corresponding to large (d = -1.08, 95% CI [-1.64, -0.52]) and medium-to-large effect sizes (d = -0.69, 95% CI [-1.22, -0.15]), respectively. During follow-up (Week 4-16), CBT showed significant increases in smoking, whereas MBT and control did not. For the entire study (baseline to Week 16), MBT showed significantly greater reductions in smoking compared to control (d = -1.6, 95% CI [-2.56, -0.66]) but CBT was not significantly different than control (d = -0.82, 95% CI [-1.77, 0.13]). There were no effects on smoking when directly comparing MBT and CBT. Quit rates were low across the sample, with no difference among conditions. MBT and CBT-versus control-significantly reduced cue-induced craving. CBT (but not MBT)-versus control-significantly improved reappraisal-based regulation of craving. Both MBT and CBT-versus control-significantly improved mindfulness-based regulation of craving.

CONCLUSIONS

MBT- and CBT-ROC-T may reduce cue-induced craving and smoking, and MBT may be more durable than CBT. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Immediate and lasting effects of different regulation of craving strategies on cue-induced craving and the late positive potential in smokers

Craving, induced by substance-related cues, contributes to continued substance use and relapse. Therefore, regulation of craving (ROC) is important for treatment success. Distraction involves disengaging from craving-inducing cues; whereas, reappraisal requires engaging with potential risks of substance use. Given this difference in elaboration, we addressed the question whether reappraisal entails lasting advantages over distraction in successful ROC. To elucidate how this is implemented neurally, we examined the late positive potential (LPP) as an electrocortical indicator of motivated attention to cues. N = 62 smokers viewed smoking-related pictures and indicated the degree of craving each picture induced. While viewing the pictures, EEG was recorded, and the participants focused on the long-term negative (LATER) or short-term positive (NOW) consequences of smoking or performed an arithmetic task to distract themselves from processing the pictures (DISTRACT). After a break, all pictures were presented again without regulation instruction (re-exposure). Results revealed that LATER and DISTRACT achieved similar degrees of immediate ROC success, but only LATER had a sustained effect during re-exposure. In contrast, LPP amplitudes were more prominently reduced during DISTRACT than LATER, and there was no difference in LPP amplitudes during re-exposure. These findings imply that it may be beneficial to engage with the risks of drug use (reappraisal) rather than avoiding triggers of craving (distraction). However, these effects do not seem to be mediated by lasting changes in cue-related motivated attention (LPP).

Emotion regulation strategies moderate the impact of negative affect induction on alcohol craving in college drinkers: an experimental paradigm

Objectives: Observational studies suggest emotion regulation (ER) as a potential treatment target for problematic college drinking. The primary aim of this laboratory study was to determine whether trait ER strategies would moderate the impact of negative affect induction on alcohol craving in college drinkers. Methods: Participants were randomly assigned to a neutral (n = 74) or a negative affect induction (n = 76) and reported their craving after the affect inductions. Results: Greater use of drinking to cope and less use of cognitive reappraisal predicted greater alcohol craving after the negative affect induction, but not after the neutral condition. In contrast, emotion suppression did not predict alcohol craving in either condition. Conclusion: Our results highlight the role of ER tendencies-particularly the benefits of cognitive reappraisal-on alcohol craving when experiencing emotional distress. Therefore, ER strategies may be an important target for college drinkers to prevent and reduce problematic drinking.

Effects of Acute Exercise on Affect, Anxiety, and Self-Esteem in Poly-Substance Dependent Inpatients

INTRODUCTION

Negative affect and anxiety frequently precede the onset of drug use in those with substance use disorder (SUD). Low self-esteem may increase the risk of relapse. We examined the short-term effects of exercise on affect, anxiety, and self-esteem in inpatients with poly-SUD.

METHODS

This is a multicenter randomized control trial (RCT) with a crossover design. Thirty-eight inpatients (37.3 ± 6.4 years; 84% male) from three clinics participated in 45 min of soccer, circuit training, and control condition (psychoeducation) in a random order. Positive and negative affect (PANAS), state anxiety (single item), and self-esteem (Rosenberg SE-scale) were measured immediately before, immediately after, 1-h, 2-h, and 4-h post-exercise. Heart rate and ratings of perceived exertion were taken. Effects were assessed using linear mixed effects models.

RESULTS

Compared to the control condition, there were significant post-exercise improvements in positive affect (β = 2.99, CI = 0.39: 5.58), self-esteem (β = 1.84, CI = 0.49: 3.20), and anxiety (β = -0.69, CI = -1.34: -0.04) after circuit training (shown) and soccer. Effects persisted 4-h post-exercise. Reductions in negative affect were observed 2-h (circuit training: β = -3.39, CI = -6.35: -1.51) and 4-h (soccer: β = -3.71, CI = -6.03: -1.39) post-exercise, respectively.

CONCLUSION

Moderately strenuous exercise undertaken in naturalistic settings may improve mental health symptoms in poly-SUD inpatients for up to 4-h post-exercise.

Right inferior frontal gyrus theta-burst stimulation reduces smoking behaviors and strengthens fronto-striatal-limbic resting-state functional connectivity: a randomized crossover trial

Introduction

Functional and anatomical irregularities in the right inferior frontal gyrus (rIFG), a ventrolateral prefrontal region that mediates top-down inhibitory control over prepotent behavioral responding, are implicated in the ongoing maintenance of nicotine dependence (ND). However, there is little research on the effects of neuromodulation of the rIFG on smoking behavior, inhibitory control, and resting-state functional connectivity (rsFC) among individuals with ND.

Methods

In this double-blind, crossover, theta-burst stimulation (TBS) study, adults with ND (N = 31; female: n = 15) completed a baseline session and were then randomized to two counterbalanced sessions of functionally neuronavigated TBS to the rIFG: continuous TBS (cTBS) on 1 day and intermittent TBS (iTBS) on another. Differences in cigarette cravings, smoking, and fronto-striatal-limbic rsFC were assessed.

Results

Relative to baseline, cTBS significantly reduced appetitive and withdrawal cravings immediately after treatment. The effects of cTBS on withdrawal craving persisted for 24 h, as well as produced a reduction in smoking. Furthermore, cTBS significantly strengthened rsFC between the rIFG pars opercularis and subcallosal cingulate (fronto-striatal circuit), and between the rIFG pars opercularis and the right posterior parahippocampal gyrus (fronto-limbic circuit). At post-24 h, cTBS-induced increase in fronto-striatal rsFC was significantly associated with less appetitive craving, while the increase in fronto-limbic rsFC was significantly associated with less withdrawal craving and smoking.

Discussion

These findings warrant further investigation into the potential value of rIFG cTBS to attenuate smoking behavior among individuals with ND.

The effects of age on the severity of problem drinking: Mediating effects of positive alcohol expectancy and neural correlates

Aging is associated with reduction in the severity of alcohol misuse. However, the psychological and neural mechanisms underlying the age-related changes remain unclear. Here, we tested the hypothesis that age-related diminution of positive alcohol expectancy (AE) mediated the effects of age on problem drinking and investigated the neural correlates of the mediating effects. Ninety-six drinkers 21-85 years of age, including social drinkers and those with mild/moderate alcohol use disorder (AUD), were assessed for global positive (GP) AE and problem drinking, each with the Alcohol Expectancy Questionnaire and Alcohol Use Disorders Identification Test (AUDIT), and with brain imaging during alcohol cue exposure. We processed imaging data with published routines; identified the correlates shared between whole-brain regression against age, GP and AUDIT scores; and performed mediation and path analyses to explore the interrelationships between the clinical and neural variables. The results showed that age was negatively correlated with both GP and AUDIT scores, with GP score completely mediating the correlation between age and AUDIT score. Lower age and higher GP correlated with shared cue responses in bilateral parahippocampal gyrus and left middle occipital cortex (PHG/OC). Further, higher GP and AUDIT scores were associated with shared cue responses in bilateral rostral anterior cingulate cortex and caudate head (ACC/caudate). Path analyses demonstrated models with significant statistical fit and PHG/OC and ACC/caudate each interrelating age to GP and GP to AUDIT scores. These findings confirmed change in positive AE as a psychological mechanism mitigating alcohol misuse as individuals age and highlighted the neural processes of cue-reactivity interrelating age and alcohol use severity.

Lack of amygdala habituation to negative emotional faces in alcohol use disorder and the relation to adverse childhood experiences

Aberrant limbic circuit reactivity to negative stimuli might be related to alterations in emotion processing and regulation in alcohol use disorder (AUD). The current study tested for the first time in AUD the hypothesis of aberrant amygdala habituation to repeated aversive stimuli-a robust and reliable neuroimaging marker for emotion processing. We explored the link between deficits in habituation to adverse childhood experience (ACE), a common risk factor for impaired emotion regulation and AUD. AUD individuals (N = 36) and healthy controls (HC; N = 26) participated in an observational case-control functional magnetic resonance imaging (fMRI) study. An established habituation index was used to investigate processing of aversive emotional faces of the amygdala. AUD individuals showed an overall deficit in amygdala habituation (right: t = 4.26, pFWE = 0.004; left: t = 4.79, pFWE ≤ 0.001). Amygdala habituation was significantly related to increased exposure to ACE in HC (t = 3.88, pFWE = 0.012), whereas this association was not observed in AUD individuals (T = 1.80, pFWE = 0.662). Further, a significant association between higher alcohol consumption and reduced amygdala habituation (right: R²  = -0.356, F = 8.736, p = 0.004; left: R²  = -0.309, F = 6.332, p = 0.015) was observed. We found novel evidence for neural alterations in emotion processing in AUD individuals, indexed by deficient amygdala habituation to negative emotional content. We replicated a prior report on a link between ACE and amygdala habituation, a well-established environmental risk factor for mental disorders and emotion dysregulation, in our control sample. Additionally, deficient amygdala habituation related to the amount of alcohol consumption in the overall sample might indicate a short-term substance effect.

Neural Correlates of Cue Reactivity and the Regulation of Craving in Substance Use Disorders

Abstract. Theoretical background: Considerable progress has been made in illuminating the neural basis of the compulsive use patterns characterizing substance use disorders. It has been suggested to utilize these findings to alleviate the health burden associated with substance use. Objective: We address how neuroimaging research can provide these benefits. Methods: Based on neurobiological models of addiction, we highlight neuroimaging research elucidating neural predictors of relapse and how treatments modify these markers. Results: With the focus on cue reactivity, brain activity related to the motivational salience of drugs and automatized use behaviors can predict relapse. Cue reactivity changes with abstinence, and it remains to be determined whether such changes confer periods of critical relapse susceptibility. Conclusions: Several established and emerging interventions modulate brain activity associated with drug value. However, executive deficits in addiction may compromise interventions targeting control-related prefrontal brain areas. Lastly, it remains more difficult to change the brain responses mediating habitual behaviors.

Brief training in regulation of craving reduces cigarette smoking

INTRODUCTION

Craving is an important contributing factor in cigarette smoking and has been added as a diagnostic criterion for addiction in the DSM-5. Cognitive-behavioral therapy and other treatments that incorporate craving regulation strategies reduce smoking and the likelihood of relapse. Although this finding suggests that the regulation of craving is an important mechanism underlying smoking cessation, whether targeted interventions that train smokers to regulate craving can directly impact real-world smoking behaviors is unclear.

METHOD

Across two pilot studies (N = 33; N = 60), we tested whether a brief, computer-delivered training session in the cognitive regulation of craving altered subsequent smoking behaviors in daily life. The study first randomly assigned participants to either a no training (control) group, or one of two Regulation of Craving Training (ROC-T) conditions. Next, all participants came into the lab and those assigned to ROC-T conditions were trained to implement a cognitive strategy to regulate their craving, by either focusing on the negative consequences of smoking, or by distracting themselves. Then, these participants underwent ROC-T during which they practiced using the strategy to regulate their craving during cue exposure. The study subsequently assessed participants' smoking via daily diaries for 3-6 days, and via self-report up to 1-month follow-up.

RESULTS

Across both studies, ROC-T conditions were associated with significant reductions in average cigarettes smoked per day, with effects persisting through follow-up.

CONCLUSION

These results confirm that the regulation of craving is an important mechanism of smoking cessation, and can be targeted via easily administered training procedures, such as ROC-T.

Association of Drug Cues and Craving With Drug Use and Relapse: A Systematic Review and Meta-analysis

Importance

Craving, which is a strong desire for drugs, is a new DSM-5 diagnostic criterion for substance use disorders (SUDs), which are the most prevalent, costly, and deadly forms of psychopathology. Despite decades of research, the roles of drug cues and craving in drug use and relapse remain controversial.

Objective

To assess whether 4 types of drug cue and craving indicators, including cue exposure, physiological cue reactivity, cue-induced craving, and self-reported craving (without cue exposure), are prospectively associated with drug use and relapse.

Data Sources

Google Scholar was searched for published studies from inception through December 31, 2018. In addition, backward and forward searches were performed on included articles to identify additional articles.

Study Selection

Included studies reported a prospective statistic that linked cue and craving indicators at time 1 to drug use or relapse at time 2, in humans.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Study characteristics and statistics were extracted and/or coded by 1 of the 2 authors and then checked by the other. Statistical analyses were performed from May to July 2021.

Main Outcomes and Measures

Random-effects models were used to calculate prospective odds ratios (ORs) representing the association between cue and craving indicators and subsequent drug use/relapse.

Results

A total of 18 205 records were identified, and 237 studies were included. Across 656 statistics, representing 51 788 human participants (21 216 with confirmed SUDs), a significant prospective association of all cue and craving indicators with drug use/relapse was found (OR, 2.05; 95% CI, 1.94-2.15), such that a 1-unit increase in cue and craving indicators was associated with more than double the odds of future drug use or relapse. A Rosenthal fail-safe analysis revealed that 180 092 null studies would need to be published to nullify this finding. Trim-and-fill analysis brought the adjusted effect size to an OR of 1.31 (95% CI, 1.25-1.38). Moderator analyses showed that some of the strongest associations were found for cue-induced craving, real cues or images, drug use outcome, same-day time lag, studies using ecological momentary assessment, and male participants.

Conclusions and Relevance

Findings from this systematic review and meta-analysis suggest that drug cue and craving indicators play significant roles in drug use and relapse outcomes and are an important mechanism underlying SUDs. Clinically, these results support incorporating craving assessment across stages of treatment, as early as primary care.

“Sound” Decisions: The Combined Role of Ambient Noise and Cognitive Regulation on the Neurophysiology of Food Cravings

Our ability to evaluate long-term goals over immediate rewards is manifested in the brain’s decision circuit. Simplistically, it can be divided into a fast, impulsive, reward “system 1” and a slow, deliberate, control “system 2.” In a noisy eating environment, our cognitive resources may get depleted, potentially leading to cognitive overload, emotional arousal, and consequently more rash decisions, such as unhealthy food choices. Here, we investigated the combined impact of cognitive regulation and ambient noise on food cravings through neurophysiological activity. Thirty-seven participants were recruited for an adapted version of the Regulation of Craving (ROC) task. All participants underwent two sessions of the ROC task; once with soft ambient restaurant noise (∼50 dB) and once with loud ambient restaurant noise (∼70 dB), while data from electroencephalography (EEG), electrodermal activity (EDA), and self-reported craving were collected for all palatable food images presented in the task. The results indicated that thinking about future (“later”) consequences vs. immediate (“now”) sensations associated with the food decreased cravings, which were mediated by frontal EEG alpha power. Likewise, “later” trials also increased frontal alpha asymmetry (FAA) —an index for emotional motivation. Furthermore, loud (vs. soft) noise increased alpha, beta, and theta activity, but for theta activity, this was solely occurring during “later” trials. Similarly, EDA signal peak probability was also higher during loud noise. Collectively, our findings suggest that the presence of loud ambient noise in conjunction with prospective thinking can lead to the highest emotional arousal and cognitive load as measured by EDA and EEG, respectively, both of which are important in regulating cravings and decisions. Thus, exploring the combined effects of interoceptive regulation and exteroceptive cues on food-related decision-making could be methodologically advantageous in consumer neuroscience and entail theoretical, commercial, and managerial implications.

Prefrontal activity during the emotional go/no-go task and computational markers of risk-based decision-making predict future relapse in alcohol use disorder

AIM

To longitudinally examine if the results of cognitive tasks or brain function during emotional or cognitive tasks can predict relapse in alcohol use disorder.

METHODS

We selected 41 patients with alcohol use disorder during hospitalization. Functional near-infrared spectroscopy (fNIRS) measured the relative change in oxygenated hemoglobin in the frontotemporal areas during an emotional go/no-go task and verbal fluency task (VFT). They performed the N-back and risk-based decision-making tasks for determining working memory or risk-based decision-making. The presence of relapse 6 months following discharge was the primary outcome.

RESULTS

Twenty-four patients (21 men, three women) remained abstinent, whereas 17 (14 men, three women) relapsed. Compared with the abstinent group, those with relapse displayed significantly decreased activation in the right frontotemporal region during the emotional go/no-go task, significantly shorter reaction time to non-emotional stimuli, and greater risk preference in the risk-based decision-making task. In the abstinent group, we observed a negative correlation between oxygenated hemoglobin and the craving scale. A logistic regression analysis demonstrated that the risk of relapse increased with smaller oxygenated hemoglobin in the right frontotemporal region (odds ratio = 0.161, p = 0.013) and with greater gambling thoughts (odds ratio = 7.04, p = 0.033).

CONCLUSION

Decreased activation in the right frontotemporal region in response to an emotional stimulus and risk preference could predict relapse in alcohol use disorder.

The neurobiology of drug addiction: cross-species insights into the dysfunction and recovery of the prefrontal cortex

A growing preclinical and clinical body of work on the effects of chronic drug use and drug addiction has extended the scope of inquiry from the putative reward-related subcortical mechanisms to higher-order executive functions as regulated by the prefrontal cortex. Here we review the neuroimaging evidence in humans and non-human primates to demonstrate the involvement of the prefrontal cortex in emotional, cognitive, and behavioral alterations in drug addiction, with particular attention to the impaired response inhibition and salience attribution (iRISA) framework. In support of iRISA, functional and structural neuroimaging studies document a role for the prefrontal cortex in assigning excessive salience to drug over non-drug-related processes with concomitant lapses in self-control, and deficits in reward-related decision-making and insight into illness. Importantly, converging insights from human and non-human primate studies suggest a causal relationship between drug addiction and prefrontal insult, indicating that chronic drug use causes the prefrontal cortex damage that underlies iRISA while changes with abstinence and recovery with treatment suggest plasticity of these same brain regions and functions. We further dissect the overlapping and distinct characteristics of drug classes, potential biomarkers that inform vulnerability and resilience, and advancements in cutting-edge psychological and neuromodulatory treatment strategies, providing a comprehensive landscape of the human and non-human primate drug addiction literature as it relates to the prefrontal cortex.

Alcohol binge drinking in adolescence and psychological profile: Can the preclinical model crack the chicken-or-egg question?

During adolescence, internal and external factors contribute to engaging with alcohol binge drinking (ABD), putting at risk the neurodevelopment of brain regions crucial for emotional control and stress coping. This research assessed the prevalence of ABD in late adolescent students of Southern Italy and characterized their psychological profile and drinking motives. Translational effects of alcohol binge drinking in the animal model were also studied. Seven hundred and fifty-nine high school students of both sexes (aged 18-20) were recruited. Alcohol Use Disorder Identification Test-Consumption (AUDIT-C), Drinking Motives Questionnaire-Revised Short Form, Millon Clinical Multiaxial Inventory-Third Ed., State-Trait Anxiety Inventory, Connor-Davidson Resilience Scale, and Basic Self-Esteem Scale identified alcohol habits, drinking motives, and psychopathological profile. Eighty-five percentage of the students drank alcohol and 28% of them engaged in ABD; AUDIT-C correlated with enhancement, coping, and conformity motives. ABD was related to a greater likelihood of presenting clinical syndromes and personality disorders, as well as low resilience and self-esteem. Thereafter, in the pre-clinical model, adolescent male rats were exposed to alcohol (3.5 g/kg) in an intermittent binge-like paradigm and tested during prolonged abstinence. Rats were evaluated for anxiety-like behavior, motivated behaviors, resilience, and stress response following a psychosocial challenge. Binge-like alcohol-exposed adolescent rats displayed high integrated z-score for social- and novelty-induced anxiety, altered motivation-driven output, decreased resilience, and a blunted HPA axis response to psychosocial stress, with respect to respective controls. Our data confirm that ABD is the chosen pattern of drinking in a significant percentage of high school students in Southern Italy, and highlights AUDIT-C score as a relevant parameter able to predict the occurrence of affective disturbances. The evidence from the preclinical model shows that ABD produces detrimental consequences in the adolescent rat brain, resulting in negative affect, emotional dysregulation, and aberrant stress response, pointing to decreasing excessive alcohol drinking as a primary goal for the global act for brain health.

Increased responsiveness to punishment of cocaine self-administration after experience with high punishment

One behavioral feature of drug addiction is continued drug use despite awareness that this causes negative consequences. Attempts to model this feature in animals typically involve punishing drug self-administration with electrical footshock to identify individuals whose drug use is differently suppressed by punishment. Here we sought to further study individual responsiveness of drug use to punishment in rats self-administering intravenous cocaine. Rats were first trained during several weeks to self-administer cocaine under a fixed-ratio 3 schedule of reinforcement. Then, their self-administration behavior was punished with increasing intensity of footshock (i.e., from 0.1 mA to 0.9 mA, every 30 min). With increasing intensity of punishment, rats first continued to self-administer cocaine before eventually stopping near completely. When retested, however, drug use became more responsive to punishment and was suppressed by a low and initially ineffective footshock intensity (i.e., 0.1 mA). This increase in responsiveness to punishment was seen in all individuals tested, albeit with varying degrees, and was acquired after one single experience with an intensity of punishment that near completely suppressed drug self-administration. Mere passive, non-contingent exposure to the same intensity, however, had no such effect. Once acquired, increased responsiveness to punishment persisted during at least one month when rats were tested every week, but not every day. Finally, increased responsiveness to punishment was not observed after exposure to a non-painful form of punishment (i.e., histamine). Overall, this study reveals that initial responsiveness of drug use to punishment can change rapidly and persistently with experience. We discuss several possible mechanisms that may account for this change in punishment responsiveness and also draw some of the implications and future perspectives for research on animal models of compulsion-like behavior.

Repetitive transcranial magnetic stimulation combined with cognitive behavioral therapy treatment in alcohol-dependent patients: A randomized, double-blind sham-controlled multicenter clinical trial

BACKGROUND

Alcohol dependence (AD) is a complex addictive disorder with a high relapse rate. Previous studies have shown that both repetitive transcranial magnetic stimulation (rTMS) and cognitive behavioral therapy (CBT) may be effective for AD, and we aim to explore more effective treatment options to reduce relapse rates for AD.

MATERIALS AND METHODS

A total of 263 AD patients were recruited. They were divided into six groups according to the location and the type of rTMS: left dorsolateral prefrontal cortex (DLPFC), right DLPFC, sham stimulation, and whether they received CBT treatment: with a fixed schedule (C1) and without a fixed plan (C0). There were included in sham rTMS + C0 group (n = 50), sham rTMS + C1 group (n = 37), right rTMS + C0 group (n = 45), right rTMS + C1 group (n = 42), left rTMS + C0 group (n = 49), left rTMS + C1 group (n = 40). We used obsessive compulsive drinking scale (OCDS), visual analogue scale (VAS), alcohol dependence scale (ADS), montreal cognitive assessment (MoCA), generalized anxiety disorder-7 (GAD-7), patient health questionnaire-9 items (PHQ-9), and Pittsburgh sleep quality index (PSQI) to assess alcohol cravings, alcohol dependence, cognition, anxiety, depression, and sleep quality. They were followed up and evaluated for relapse.

RESULTS

The sham rTMS + C0 group relapse rate was significantly higher than the right rTMS + C1 group (P = 0.006), the left rTMS + C0 group (P = 0.031), the left rTMS + C1 group (P = 0.043). The right rTMS + C0 group showed significantly higher relapse rate compared to the right rTMS + C1 group (P = 0.046). There was no significant difference in relapse rates between other groups. The repeated-measures ANOVA showed an interaction effect between group and time was significant in the rate of patient health questionnaire-9 items (PHQ-9) scale reduction (P = 0.020). Logistic analysis indicated that smoking and alcohol consumption were independent determinants of relapse (P < 0.05). At 24 weeks of follow-up, Kaplan-Meier survival analysis reveal that there is statistically significant relapse rate between six groups (P = 0.025), left rTMS + C1 group has the best treatment effect for alcohol dependent patients. Cox regression analysis confirmed that current smoking, total cholesterol, and total bilirubin (TBIL) level were risk factors of relapse (P < 0.05).

CONCLUSION

This study is the first to suggest that the combination of rTMS and CBT may be a potentially effective treatment for reducing relapse.

Effects of acupuncture stimulation on brain activation induced by cue-elicited alcohol craving

Acupuncture has been shown to be effective on alcohol use disorder. However, the underlying mechanism remains poorly understood. To investigate the effects of Shenmen (HT7) acupoint on brain activation induced by cue-elicited alcohol craving, 30 right-handed healthy light to moderate alcohol drinkers were recruited from the community. They were randomly assigned to undergo acupuncture either at HT7 (experimental acupoint, n = 15) or Jingqu (LU8, control acupoint, n = 15) acupoints. This randomized controlled study was performed in Daegu Haany University and Daegu-Gyeongbuk Medical Innovation Foundation, Republic of Korea. Recruitment and data collection were conducted from December 2018 to May 2019. The results showed that after acupuncture at HT7 acupoint, the activation of orbitofrontal cortex and dorsolateral prefrontal cortex was greatly increased, while the activation of dorsolateral prefrontal cortex was obviously reduced, and subject's craving for alcohol was reduced when he/she seeing alcohol-related video clips involving various alcohols (beer, wine, or soju) or drinking scenarios. Acupuncture at HT7 more greatly reduced subject's alcohol cravings than acupuncture at LU8 acupoint. These findings suggest that acupuncture can improve the self-control of mild to moderate social drinkers through the activation of the orbitofrontal cortex and dorsolateral prefrontal cortex, thereby reducing the craving for alcohol. The study protocol was approved by the Institutional Review Board of Daegu Haany University Korean Medicine Hospital, Republic of Korea (approval No. DHUMC-D-18026-PRO-02) on November 30, 2018.

Mindfulness-based interventions for eating disorders: The potential to mobilize multiple associative-learning change mechanisms

Mindfulness is a two-component skill that includes mindful awareness (attentional monitoring of present moment experience) and mindful acceptance (adopting an attitude of acceptance toward this experience). Although mindfulness-based interventions (MBIs) are efficacious for many conditions, there is a lack of research on MBIs for eating disorders (EDs). We propose that MBIs may be promising for EDs given their potential to mobilize not one, but multiple associative-learning change mechanisms in EDs-defined as adaptive processes of change involving one of two forms of associative-learning: Pavlovian and operant learning. We hypothesize how MBIs-via increasing either mindful awareness or mindful acceptance-may mobilize up to eight associative-learning change mechanisms, two involving Pavlovian learning, and six involving operant learning. We also elaborate on similarities and differences between MBIs and CBT approaches for EDs, as well as opportunities for synergy. Finally, we present recommendations for future research related to the development and evaluation of novel MBI interventions for EDs and the testing of mechanisms and patient-treatment matching hypotheses.

Drinking reduction during cognitive behavioral therapy for alcohol use disorder is associated with a reduction in anterior insula-bed nucleus of the stria terminalis resting-state functional connectivity

BACKGROUND

Connectivity between the anterior insula (AI) and the bed nucleus of the stria terminalis (BNST) may play a role in negative emotions that drive compulsive drinking in patients with alcohol use disorder (AUD). We hypothesized that reductions in drinking during cognitive behavioral therapy (CBT), an effective treatment that teaches regulation (coping) skills for managing negative emotions during abstinence, would be associated with reductions in resting-state functional connectivity (RSFC) between the AI and the BNST.

METHODS

We included 18 patients with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of AUD who were (1) seeking treatment and (2) drinking heavily at baseline. We measured RSFC as Pearson's correlation between the BNST and multiple regions of interest in the insula at baseline and after completion of 12 weeks of a single-arm clinical trial of outpatient CBT. We also assessed the number of heavy drinking days over the previous 28 days (NHDD) at both time points. We used 1-sample t-tests to evaluate AI-BNST RSFC at baseline, paired t-tests to evaluate changes in AI-BNST RSFC from pre-CBT to post-CBT, and linear regression to evaluate the relationship between changes in AI-BNST RSFC and NHDD.

RESULTS

We found a significant positive RSFC between the AI and the BNST at baseline (p = 0.0015). While there were no significant changes in AI-BNST RSFC from pre- to post-CBT at the group level (p = 0.42), we found that individual differences in reductions in AI-BNST RSFC from pre- to post-CBT were directly related to reductions in NHDD from pre- to post-CBT (r = 0.73, p = 0.0008).

CONCLUSIONS

These findings provide preliminary evidence that reduced AI-BNST RSFC may be a mechanism of drinking reduction in AUD and that AI-BNST RSFC may be a target for CBT and possibly other treatments.

Neural responses to negative events and subsequent persistence behavior differ in individuals recovering from opioid use disorder compared to controls

Background: Negative emotion is associated with substance craving and use in individuals recovering from substance use disorders, including prescription opioid use disorder (POUD). Decisions to abandon or persist towards a goal after negative emotion-eliciting events, and neural responses that shape such decisions, may be important in maintaining recovery from POUD.Objectives: We examined differences in neural responses to negative events and subsequent persistence decisions in individuals recovering from POUD without a history of a substance use disorder. Methods: 20 individuals with POUD (POUD group: 4 females, abstinent 2-3 weeks after admission to an inpatient treatment facility post-detoxification, no other substance use disorder), and 20 individuals with no substance use history (control group: 6 females) completed a persistence-after-setbacks task during functional magnetic resonance imaging. Participants advanced along a path toward a reward; after encountering each negative event (i.e., progress-erasing setback), participants made decisions to persist or abandon the path. Persistence decision rates were compared between groups and blood-oxygen-level-dependent signal to negative events was analyzed within a striatum region of interest (ROI) as well as whole-brain.Results: The POUD group persisted less (t(38) = 2.293, p = .028, d = .725) and showed lower striatum (left ventral putamen) signal to negative events compared to the control group (p < .05, corrected for striatum ROI).Conclusions: In POUD, neural and behavioral responses to negative events differ from controls. These differences are a target for research to address whether POUD treatment increases persistence and striatum responses to negative events and improves recovery outcomes.

Factors of Negative Affect in Elderly Patients With Substance Use Disorders During COVID-19 Pandemic

Background: The outbreak of the novel coronavirus disease 2019 (COVID-19) has become the greatest public health emergency and has attracted global attention. During the COVID-19 pandemic, the negative affect (NA) of elderly patients with substance use disorders (SUDs) has also become a more serious public concern. The current study aims to clarify the NA and its influencing factors in elderly patients with SUDs during the pandemic. Methods: Two psychiatrists conducted semi-structured interviews with 77 SUD patients aged above 50 years to collect their demographical information and certain drug use characteristics. Barratt Impulse Scale and the Positive and Negative Affect Scale were used to obtain information about patients' self-reported impulsivity and NA. Results: Univariate linear regression analysis showed that NA was positively correlated with the frequency of drug use, type of SUDs, cravings during COVID-19, and impulsivity. Multiple linear regression analysis showed that being female, higher frequency of drug use, stronger cravings, and greater impulsiveness jointly accounted for the variation of NA in elderly patients with SUDs. Conclusions: This study confirmed that, during the COVID-19 pandemic, gender, frequency of drug use, cravings, and impulsivity were associated with NA in elderly patients with SUDs. This study provided a theoretical basis for clinicians to reduce the patients' NA.

Imprecise action selection in substance use disorder: Evidence for active learning impairments when solving the explore-exploit dilemma

BACKGROUND

Substance use disorders (SUDs) are a major public health risk. However, mechanisms accounting for continued patterns of poor choices in the face of negative life consequences remain poorly understood.

METHODS

We use a computational (active inference) modeling approach, combined with multiple regression and hierarchical Bayesian group analyses, to examine how treatment-seeking individuals with one or more SUDs (alcohol, cannabis, sedatives, stimulants, hallucinogens, and/or opioids; N = 147) and healthy controls (HCs; N = 54) make choices to resolve uncertainty within a gambling task. A subset of SUDs (N = 49) and HCs (N = 51) propensity-matched on age, sex, and verbal IQ were also compared to replicate larger group findings.

RESULTS

Results indicate that: (a) SUDs show poorer task performance than HCs (p = 0.03, Cohen's d = 0.33), with model estimates revealing less precise action selection mechanisms (p = 0.004, d = 0.43), a lower learning rate from losses (p = 0.02, d = 0.36), and a greater learning rate from gains (p = 0.04, d = 0.31); and (b) groups do not differ significantly in goal-directed information seeking.

CONCLUSIONS

Findings suggest a pattern of inconsistent behavior in response to positive outcomes in SUDs combined with a tendency to attribute negative outcomes to chance. Specifically, individuals with SUDs fail to settle on a behavior strategy despite sufficient evidence of its success. These learning impairments could help account for difficulties in adjusting behavior and maintaining optimal decision-making during and after treatment.

Imprecise action selection in substance use disorder: Evidence for active learning impairments when solving the explore-exploit dilemma

BACKGROUND

Substance use disorders (SUDs) are a major public health risk. However, mechanisms accounting for continued patterns of poor choices in the face of negative life consequences remain poorly understood.

METHODS

We use a computational (active inference) modeling approach, combined with multiple regression and hierarchical Bayesian group analyses, to examine how treatment-seeking individuals with one or more SUDs (alcohol, cannabis, sedatives, stimulants, hallucinogens, and/or opioids; N = 147) and healthy controls (HCs; N = 54) make choices to resolve uncertainty within a gambling task. A subset of SUDs (N = 49) and HCs (N = 51) propensity-matched on age, sex, and verbal IQ were also compared to replicate larger group findings.

RESULTS

Results indicate that: (a) SUDs show poorer task performance than HCs (p = 0.03, Cohen's d = 0.33), with model estimates revealing less precise action selection mechanisms (p = 0.004, d = 0.43), a lower learning rate from losses (p = 0.02, d = 0.36), and a greater learning rate from gains (p = 0.04, d = 0.31); and (b) groups do not differ significantly in goal-directed information seeking.

CONCLUSIONS

Findings suggest a pattern of inconsistent behavior in response to positive outcomes in SUDs combined with a tendency to attribute negative outcomes to chance. Specifically, individuals with SUDs fail to settle on a behavior strategy despite sufficient evidence of its success. These learning impairments could help account for difficulties in adjusting behavior and maintaining optimal decision-making during and after treatment.

Predictors of Changes in Alcohol Craving Levels during a Virtual Reality Cue Exposure Treatment among Patients with Alcohol Use Disorder

BACKGROUND/OBJECTIVE

Determining the predictive variables associated with levels of alcohol craving can ease the identification of patients who can benefit from treatments. This study aimed to describe changes (improvement or no change/deterioration) in alcohol craving levels and explore the predictors of these changes from admission to discharge in outpatients with alcohol use disorder (AUD) undergoing treatment-as-usual (TAU), or treatment-as-usual supplemented with virtual reality cue-exposure therapy (TAU + VR-CET).

METHOD

A prospective cohort study was conducted amongst 42 outpatients with AUD (n = 15 TAU + VR-CET and n = 27 TAU) from a clinical setting. Changes in the levels of alcohol craving between admission and discharge were assessed with the Multidimensional Alcohol Craving Scale. Sociodemographic characteristics (age, gender, education, and socioeconomic and civil status), cognitive-affective behavioral patterns (AUD severity, abstinence duration, psychiatric comorbidity, state anxiety, attentional bias, and substance use), and type of treatment (TAU + VR-CET and only TAU) were also evaluated.

RESULTS

The TAU + VR-CET group showed greater changes of improvement in the levels of alcohol craving than the TAU group (χ2 = 10.996; p = 0.001). Intragroup changes in alcohol craving from pre to post-treatment were significant in the TAU + VR-CET group (χ2 = 13.818; p = 0.003) but not within the TAU group (χ2 = 2.349; p = 0.503). The odds of an improvement in any of the craving levels between pre- and post-test was 18.18 (1/0.055) times higher in the TAU + VR-CET group with respect to the TAU group. The use of illicit drugs in the month prior to the test increased the odds of having a positive change by 18.18 (1/0.055) with respect to not having consumed.

CONCLUSIONS

Including VR-CET in TAU programs may provide benefits in the treatment of AUDs mainly among patients with intense alcohol craving and individuals having used illicit substances prior to treatment.

Distress tolerance and special alcohol metacognitions behave differently in the association of negative affect with alcohol-related patterns in men with problematic alcohol use in the abstinence phase

Negative affect may be related to alcohol-related patterns (e.g., craving and problematic alcohol use). Distress intolerance and positive and negative alcohol-related metacognitions may be underlying mechanisms in this link. This study aimed to evaluate the effect of negative affect including depressive, anxious, and stress symptoms on alcohol craving and problematic alcohol use via the paths of distress tolerance and both positive and negative alcohol-related metacognitions. Three hundred men with problematic alcohol use during the abstinence phase completed psychological and clinical measures. Results showed that craving and negative alcohol metacognitions mediated the relationship between negative affect and problematic alcohol use. Negative affect had a direct and positive effect on craving and indirect effect via distress intolerance and positive alcohol metacognitions. In turn, distress intolerance and positive alcohol metacognitions indirectly and positively affected problematic alcohol use via craving. The study indicates that distress tolerance and distinct alcohol metacognitions may be differently related to various patterns of alcohol-related problems, such that alcohol drinkers with high levels of negative affect, distress intolerance, and positive alcohol metacognitions show higher levels of craving, while high negative affect in relation to high negative alcohol metacognitions and alcohol craving is related to the perpetuation of alcohol use or problematic alcohol use.

Intensive longitudinal methods for studying the role of self-regulation strategies in substance use behavior change

Purpose of review

Many psychosocial interventions for substance use disorders (SUDs) focus on teaching self-regulation strategies. Research using intensive longitudinal methods (ILM), such as ecological momentary assessment and daily diaries, is critical for elucidating if and how these strategies function as mechanisms of change among individuals with SUDs. We review this emerging area of research.

Recent findings

We found a small number of studies using ILM to study self-regulation strategies in SUD (n=18 studies), with most conducted among college student drinkers (n=9) and cigarette smokers (n=7), and few among treatment-engaged individuals, and those with other drug use disorders. There is preliminary evidence that the use of specific self-regulation strategies commonly taught in psychosocial interventions for SUDs (i.e., cognitive reappraisal, problem solving, stimulus control, harm reduction) is associated with decreased momentary or daily substance use, at the within-person level.

Summary

There is a need for further ILM research on self-regulation strategies as mechanisms of substance use behavior change. Such research can inform the development, refinement, and personalization of interventions that teach self-regulation strategies, including mobile interventions that facilitate strategy use in the moment. One key next step is developing psychometrically validated ILM assessments of self-regulation strategy use.

Regulating food craving: From mechanisms to interventions

Craving, defined here as a strong desire to eat, is a common experience that drives behavior. Here we discuss the concept of craving from historical, physiological, and clinical perspectives, and review work investigating the effects of cue reactivity and cue-induced craving on eating and weight outcomes, as well as underlying neural mechanisms. We also highlight the significance of cue reactivity and craving in the context of our "toxic food environment" and the obesity epidemic. We then summarize our work developing the Regulation of Craving (ROC) task, used to test the causal effects of cognitive strategies on craving for food and drugs as well as the underlying neural mechanisms of such regulation. Next, we review our recent development of a novel ROC-based intervention that trains individuals to use cognitive strategies to regulate craving, with promising effects on subsequent food choice and caloric consumption. We end by discussing future directions for this important line of work.