Abnormal cortical thickness in heroin-dependent individuals

Regional cerebral metabolism alterations and functional connectivity in individuals with opioid use disorder: An integrated resting-state PET/fMRI study

Individuals with opioid use disorder (OUD) have been reported to show abnormal brain metabolism and impaired coupling among brain networks such as the default mode network (DMN), salience network (SN), and executive control network (ECN). However, the characteristics of brain glucose metabolism and its related functions in the brain networks in individuals with OUD remain unknown. Thirty-six individuals with OUD and thirty matched healthy controls (HCs) were recruited in this integrated positron emission tomography/magnetic resonance imaging (PET/MRI) study. Differences in glucose metabolism were analyzed by using 18F-fluorodeoxyglucose (18F-FDG), and the corresponding coupling characteristics of the individuals with OUD were also analyzed. The individuals with OUD showed widespread bilateral hypometabolism in the middle temporal gyrus (MTG), superior temporal gyrus, angular gyrus, supramarginal gyrus, inferior parietal lobe, Rolandic operculum, and left insula, but obvious hypermetabolism in the brainstem and left cerebellum. Meanwhile, in individuals with OUD, the hypometabolism of right MTG which is included in the DMN was accompanied by decreased coupling with the left superior frontal gyrus and right superior parietal gyrus which are included in the ECN. Furthermore, individuals with OUD showed a positive correlation between the duration of heroin use and glucose metabolism of the left MTG. The individuals with OUD were characterized by widespread bilateral hypometabolism in the temporal and parietal regions but obvious hypermetabolism in the brainstem and left cerebellum. The results suggest that the hypometabolism in the temporal and parietal regions might be related to DMN dysfunction and the hypermetabolism in the brainstem and left cerebellum may be compensate for other brain regions showing hypometabolism. In particular, hypometabolism in the self-referential-related DMN regions in OUD might attenuate their relationships with the inhibitory-control-related ECN regions. These findings highlight the importance of evaluating the metabolic and functional profiles of the right MTG in future studies on the treatment of OUD.

Relapse risk revealed by degree centrality and cluster analysis in heroin addicts undergoing methadone maintenance treatment

BACKGROUND

Based on hubs of neural circuits associated with addiction and their degree centrality (DC), this study aimed to construct the addiction-related brain networks for patients diagnosed with heroin dependence undertaking stable methadone maintenance treatment (MMT) and further prospectively identify the ones at high risk for relapse with cluster analysis.

METHODS

Sixty-two male MMT patients and 30 matched healthy controls (HC) underwent brain resting-state functional MRI data acquisition. The patients received 26-month follow-up for the monthly illegal-drug-use information. Ten addiction-related hubs were chosen to construct a user-defined network for the patients. Then the networks were discriminated with K-means-clustering-algorithm into different groups and followed by comparative analysis to the groups and HC. Regression analysis was used to investigate the brain regions significantly contributed to relapse.

RESULTS

Sixty MMT patients were classified into two groups according to their brain-network patterns calculated by the best clustering-number-K. The two groups had no difference in the demographic, psychological indicators and clinical information except relapse rate and total heroin consumption. The group with high-relapse had a wider range of DC changes in the cortical-striatal-thalamic circuit relative to HC and a reduced DC in the mesocorticolimbic circuit relative to the low-relapse group. DC activity in NAc, vACC, hippocampus and amygdala were closely related with relapse.

CONCLUSION

MMT patients can be identified and classified into two subgroups with significantly different relapse rates by defining distinct brain-network patterns even if we are blind to their relapse outcomes in advance. This may provide a new strategy to optimize MMT.

Increased spontaneous activity of the superior frontal gyrus with reduced functional connectivity to visual attention areas and cerebellum in male smokers

Background

Chronic smokers have abnormal spontaneous regional activity and disrupted functional connectivity as revealed by previous neuroimaging studies. Combining different dimensions of resting-state functional indicators may help us learn more about the neuropathological mechanisms of smoking.

Methods

The amplitude of low frequency fluctuations (ALFF) of 86 male smokers and 56 male non-smokers were first calculated. Brain regions that displayed significant differences in ALFF between two groups were selected as seeds for further functional connectivity analysis. Besides, we examined correlations between brain areas with abnormal activity and smoking measurements.

Results

Increased ALFF in left superior frontal gyrus (SFG), left medial superior frontal gyrus (mSFG) and middle frontal gyrus (MFG) as well as decreased ALFF in right calcarine sulcus were observed in smokers compared with non-smokers. In the seed-based functional connectivity analysis, smokers showed attenuated functional connectivity with left SFG in left precuneus, left fusiform gyrus, left lingual gyrus, left cerebellum 4 5 and cerebellum 6 as well as lower functional connectivity with left mSGF in left fusiform gyrus, left lingual gyrus, left parahippocampal gyrus (PHG), left calcarine sulcus, left cerebellum 4 5, cerebellum 6 and cerebellum 8 (GRF corrected, Pvoxel < 0.005, Pcluster<0.05). Furthermore, attenuated functional connectivity with left mSGF in left lingual gyrus and PHG displayed a negative correlation with FTND scores (r = −0.308, p = 0.004; r = −0.326, p = 0.002 Bonferroni corrected).

Conclusion

Our findings of increased ALFF in SFG with reduced functional connectivity to visual attention areas and cerebellum subregions may shed new light on the pathophysiology of smoking.

The effect of repetitive transcranial magnetic stimulation on electroencephalography microstates of patients with heroin-addiction

The effects of transcranial magnetic stimulation in treating substance use disorders are gaining attention; however, most existing studies used subjective measures to examine the treatment effects. Objective electroencephalography (EEG)-based microstate analysis is important for measuring the efficacy of transcranial magnetic stimulation in patients with heroin addiction. We investigated dynamic brain activity changes in individuals with heroin addiction after transcranial magnetic stimulation using microstate indicators. Thirty-two patients received intermittent theta-burst stimulation (iTBS) over the left dorsolateral prefrontal cortex. Resting-state EEG data were collected pre-intervention and 10 days post-intervention. The feature values of the significantly different microstate classes were computed using a K-means clustering algorithm. Four EEG microstate classes (A-D) were noted. There were significant increases in the duration, occurrence, and contribution of microstate class A after the iTBS intervention. K-means classification accuracy reached 81.5%. The EEG microstate is an effective improvement indicator in patients with heroin addiction treated with iTBS. Microstates were examined using machine learning; this method effectively classified the pre- and post-intervention cohorts among patients with heroin addiction and healthy individuals. Using EEG microstate to measure heroin addiction and further exploring the effect of iTBS in patients with heroin addiction merit clinical investigation.

Neuroimaging mechanisms in short-term heroin- and methamphetamine-abstinent users: Similarities and differences

Heroin and methamphetamine cause great damage to individuals and society. However, numerous withdrawal mechanisms remain unidentified. In this study, 19 heroin short-term abstinent (HSTA) patients, 20 methamphetamine short-term abstinent (MSTA) patients, and 27 healthy controls (HCs) were scanned using multimodal magnetic resonance imaging. Degraded nodes of fiber tracts were identified using automated fiber quantification. Voxel- and surface-based morphometric measurements were performed to determine the gray matter volume and cortical thickness. The MSTA and HSTA groups had abnormal diffusion metrics in a variety of bilateral corticospinal tract (CST) and left superior longitudinal tract (SLT) nodes compared with the HC group. The MSTA patients reported more severely disrupted diffusion metrics in certain nodes of the bilateral anterior thalamic radiation and left inferior fronto-occipital tract than the HSTA patients. The MSTA and HSTA groups exhibited identical cortical damage in the fusiform and superior temporal gyri, as well as in the superior frontal gyrus, posterior cerebellum, and precentral gyrus. Extensive differences in gray matter lesions were observed between the MSTA and HSTA groups. Neuroimaging mechanisms of short-term abstinence may aid in the development of rehabilitation strategies.

Longitudinal resting-state functional connectivity changes in the insular subdivisions of abstinent individuals with opioid use disorder

The insular cortex plays a critical role in reward circuitry involved with drug craving in substance use disorders. This study aimed to investigate whether opioid use disorder exhibit functional alterations in the insular circuitry after abstinence. Sixty-one opioid use disorder underwent resting-state and 3D-T1-weighted magnetic resonance imaging and completed craving questionnaires at baseline and after 8 months of abstinence. Changes in resting-state functional connectivity in the insular cortex and their correlations with craving were analyzed. Craving was reduced at follow-up compared with baseline. Compared with that at baseline, there was significantly increased resting-state functional connectivity between the right insular cortex and the superior frontal gyrus/anterior cingulate gyrus (family-wise error corrected) at follow-up. Changes in the functional connectivity of the right dorsal anterior insula/posterior insula with the bilateral superior frontal gyrus were negatively correlated with changes in craving. Our results demonstrated the presence of changes in functional connectivity of the insula in opioid use disorder after protracted abstinence, providing novel evidence of a correlation between craving changes and changes in the neurocircuitry of insular cortex subdivision after abstinence. This study reveals the possibility of neuroplasticity after protracted abstinence, providing insight for future abstinence therapies and rehabilitation procedures for patients with substance use disorders.

Partial recovery of the left DLPFC-right insula circuit with reduced craving in abstinent heroin users: a longitudinal study

The phenomenon of brain recovery after long-term abstinence has been reported in substance use disorders. However, few longitudinal studies have been conducted to observe the potential recovery in heroin users, and little is known about the neural mechanism underlying the decreased craving after prolonged abstinence. The 8-month longitudinal study was carried out in 29 heroin users and 30 healthy controls. By choosing the L_DLPFC, which was activated by the heroin cue as the seeding region, different brain connection patterns were compared between healthy controls and heroin users by using Granger causality analysis (GCA) at baseline. Then, a paired t test was employed to detect the potential recovery of L_DLPFC circuits after prolonged abstinence. The visual analog scale (VAS) and trail-making test-A (TMT-A) were adopted to investigate craving and cognitive control impairment, respectively. The neuroimaging changes were then correlated with behavioral improvements. Similar analyses were applied for the mirrored right DLPFC to verify the lateralization hypothesis of the DLPFC in addiction. In the longitudinal study, enhanced GCA coefficients were observed in the L_DLPFC-R_insula circuit of heroin users after long-term abstinence and were associated with craving score changes. At baseline, decreased GCA coefficients from the left DLPFC to the bilateral SMA and right putamen, together with the reduced GCA strength from the bilateral OFC to the left DLPFC, were found between HUs and HCs. Our findings extended the brain recovery phenomenon into the field of heroin and suggested that the increased regulation of the L_DLPFC over the insula after prolonged abstinence was important for craving inhibition.

Recovery of superior frontal gyrus cortical thickness and resting-state functional connectivity in abstinent heroin users after 8 months of follow-up

Compared with healthy controls, heroin users (HUs) show evidence of structural and functional brain alterations. However, little is known about the possibility of brain recovery after protracted heroin abstinence. The purpose of this study was to investigate whether brain recovery is possible after protracted abstinence in HUs. A total of 108 subjects with heroin addiction completed structural and functional scans, and 61 of those subjects completed 8-month follow-up scans. Resting-state data and 3D-T1 MR images were collected for all participants, first at baseline and again after 8 months. Cognitive function and craving were measured by the Trail Making Test-A (TMT-A) and Visual Analog Scale for Craving, respectively. The cortical thickness and resting-state functional connectivity (RSFC) differences were then analyzed and compared between baseline and follow-up, and correlations were obtained between neuroimaging and behavioral changes. HUs demonstrated improved cognition (shorter TMT-A time) and reduced craving at the follow-up (HU2) relative to baseline (HU1), and the cortical thickness in the bilateral superior frontal gyrus (SFG) was significantly greater at HU2 than at HU1. Additionally, the RSFC of the left SFG with the inferior frontal gyrus (IFG), insula, and nucleus accumbens and that of the right SFG with the IFG, insula and orbitofrontal cortex (OFC) were increased at HU2. The changes in TMT-A time were negatively correlated with the RSFC changes between the left SFG and the bilateral IFG, the bilateral caudate, and the right insula. The changes in craving were negatively correlated with the RSFC changes between the left OFC and the bilateral SFG. Our results demonstrated that impaired frontal-limbic neurocircuitry can be partially restored, which might enable improved cognition as well as reduced craving in substance-abusing individuals. We provided novel scientific evidence for the partial recovery of brain circuits implicated in cognition and craving after protracted abstinence.

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.

Brain morphometry in adults with gambling disorder

Little is known regarding the brain substrates of Gambling Disorder, including surface brain morphometry, and whether these are linked to the clinical profile. A better understanding of the brain substrates will likely help determine targets to treat patients. Hence, the aim of this study was two-fold, that is to examine surface-based morphometry in 17 patients with gambling disorder as compared to norms of healthy individuals (2713 and 2790 subjects for cortical and subcortical anatomical scans, respectively) and to assess the clinical relevance of morphometry in patients with Gambling Disorder. This study measured brain volume, surface and thickness in Gambling Disorder. We compared these measures to those of a normative database that controlled for factors such as age and sex. We also tested for correlations with gambling-related behaviors, such as gambling severity and duration, impulsivity, and depressive symptoms (assessed using the South Oaks Gambling Screen, years of gambling, Barratt Impulsiveness Scale, and Beck Depression Inventory, respectively). Patients displayed thinner prefrontal and parietal cortices, greater volume and thickness of the occipital and the entorhinal cortices, and greater volume of subcortical regions as compared to the norms of healthy individuals. There were positive correlations between surface area of occipital regions and depressive symptoms. This work contributes to better characterize the brain substrates of Gambling Disorder, which appear to resemble those of substance use disorders and Internet Gaming Disorder.

Structural MRI and functional connectivity features predict current clinical status and persistence behavior in prescription opioid users

Prescription opioid use disorder (POUD) has reached epidemic proportions in the United States, raising an urgent need for diagnostic biological tools that can improve predictions of disease characteristics. The use of neuroimaging methods to develop such biomarkers have yielded promising results when applied to neurodegenerative and psychiatric disorders, yet have not been extended to prescription opioid addiction. With this long-term goal in mind, we conducted a preliminary study in this understudied clinical group. Univariate and multivariate approaches to distinguishing between POUD (n = 26) and healthy controls (n = 21) were investigated, on the basis of structural MRI (sMRI) and resting-state functional connectivity (restFC) features. Univariate approaches revealed reduced structural integrity in the subcortical extent of a previously reported addiction-related network in POUD subjects. No reliable univariate between-group differences in cortical structure or edgewise restFC were observed. Contrasting these mixed univariate results, multivariate machine learning classification approaches recovered more statistically reliable group differences, especially when sMRI and restFC features were combined in a multi-modal model (classification accuracy = 66.7%, p < .001). The same multivariate multi-modal approach also yielded reliable prediction of individual differences in a clinically relevant behavioral measure (persistence behavior; predicted-to-actual overlap r = 0.42, p = .009). Our findings suggest that sMRI and restFC measures can be used to reliably distinguish the neural effects of long-term opioid use, and that this endeavor numerically benefits from multivariate predictive approaches and multi-modal feature sets. This can serve as theoretical proof-of-concept for future longitudinal modeling of prognostic POUD characteristics from neuroimaging features, which would have clearer clinical utility.

Fronto-temporal cortical atrophy in 'nyaope' combination heroin and cannabis use disorder

Sub-Saharan Africa is one of the top three regions with the highest rates of opioid-related premature mortality. Nyaope is the street name for what is believed to be a drug cocktail in South Africa although recent research suggests that it is predominantly heroin. Nyaope powder is most commonly smoked together with cannabis, a drug-use pattern unique to the region. Due to the increasing burden of this drug in low-income communities and the absence of human structural neuroimaging data of combination heroin and cannabis use disorder, we initiated an important cohort study in order to identify neuroanatomical sequelae. Twenty-eight male nyaope users and thirty healthy, matched controls were recruited from drug rehabilitation centers and the community, respectively. T1-weighted MRI images were obtained using a 3 T General Electric Discovery and cortical thickness was examined and compared. Nyaope users displayed extensive grey matter atrophy in the right hemispheric medial orbitofrontal, rostral middle frontal, superior temporal, superior frontal, and supramarginal gyri (two-sided t-test, p < 0.05, corrected for multiple comparisons). Our findings indicate cortical abnormality in nyaope users in regions involved in impulse control, decision making, social- and self-perception, and working memory. Importantly, affected brain regions show large overlap with the pattern of cortical abnormalities shown in heroin use disorder.

Impulsivity in heroin-dependent individuals: structural and functional abnormalities within frontostriatal circuits

High levels of impulsivity are a risk factor for the initiation of heroin use and a core behavioral characteristic of heroin dependence. Impulsivity also contributes to the maintenance of drug use and hinders effective therapy. Here we sought to identify neuroimaging markers of impulsivity in heroin-dependent individuals (HDI), with a focus on the nucleus accumbens (NAc), a key region implicated in impulsivity and drug addiction generally. Volume and resting-state functional connectivity (RSFC) differences of the bilateral NAc were investigated between 21 HDI and 21 age-, gender-, nicotine-, alcohol-matched healthy controls (HC). The neuroimaging results were then correlated with the Barratt Impulsivity Scales (BIS-11). Higher motor impulsivity (t = 2.347, p = 0.0253) and larger right NAc volume (F (1,38) = 4.719, p = 0.036) was observed in HDI. The right NAc volume was positively correlated with BIS total (r = 0.6196, p = 0.0239) /motor (r = 0.5921, p = 0.0330) scores in HC and BIS motor (r = 0.5145, p = 0.0170) score in HDI. A negative correlation was found between RSFC of the right NAc-bilateral superior frontal gyrus (SFG) and motor impulsivity in HDI (left: r=-0.6537, p = 0.0013; right: r=-0.6167, p = 0.0029) and HC (left: r=-0.6490,p = 0.0164; right: r=-0.6993, p = 0.0078). We aimed to reveal novel multimodality neuroimaging biomarkers of the higher impulsivity in HDI by focusing on the NAc and corresponding functional circuits. Higher motor impulsivity was observed in HDI. Furthermore, the volume of the right NAc and the RSFC strength of right NAc-SFG could be neuroimaging biomarkers for the severity of impulsivity in HDI. These potential biomarkers could be a target for novel treatments in HDI.

Biomarkers to predict staging and treatment response in opioid dependence: A narrative review

Opioid use disorder is a devastating disorder with a high burden in terms of overdose mortality, with an urgent need for more personalized prevention or therapeutic interventions. For this purpose, the description and validation of biological measures of staging or treatment response is a highly active research field. We conducted a narrative review on the pathophysiology of opioid use disorder to propose staging of the disease and search for research studies proposing or demonstrating the predictive value of biomarkers. We propose a IV stage description of opioid use disorder, from (I) vulnerability stage to (II) disease progression, (III) constituted opioid dependence and were several type of treatments can be applied, to the reach a (IV) modified health state. We classified biomarkers studies according to the stage of the disorder they were intended to predict, and to the three categories of methods they used: anatomical and functional aspects of the brain, genetic/transcriptomic/epigenetic studies, and lastly biomarkers of systemic modifications associated with opioid use disorder, especially regarding the immune system. Most studies predicting Stage III that we reviewed collected data from small samples sizes and were cross-sectional association studies comparing opioid dependent patients and control groups. Pharmacogenetic biomarkers are proposed to predict treatment response. Future research should now emphasize prospective studies, replication in independent samples, and predictive value calculation of each biomarker. The most promising results are multimodal evaluations to be able to measure the state of the brain reward system in living individuals.

Functional connectome-based biomarkers predict chronic codeine-containing cough syrup dependent

PURPOSE

Codeine-containing cough syrup (CCS) is considered among the most popular drugs of abuse in adolescents worldwide. Accurate prediction and identification of CCS dependent (CCSD) users are crucial. This study aimed to identify a brain-connectome-based predictor of CCSD using a machine learning model based on a ten-fold cross-validation logistic regression (LR) classifier.

METHODS

40 CCSD users and 40 healthy control (HC) subjects underwent functional magnetic resonance imaging to construct weight functional networks. Partial correlation analysis was used to analyze relations between abnormal network metrics and clinical characteristics (BIS total scores, CCS abuse duration, and mean CCS dose) in CCSD. A ten-fold cross-validation LR classifier was used to classify CCSD users and HC subjects.

RESULTS

The CCSD group showed significantly abnormal nodes and connections in the right posterior cingulate, right middle insula, bilateral prefrontal cortex, parietal lobe, temporal lobe, occipital lobe, and cerebellum. Furthermore, higher characteristic path length and lower clustering coefficient (Cp), global efficiency, and local efficiency (Eloc) were observed in the global topologies in CCSD. The abnormal global properties (Cp and Eloc) and node properties of the prefrontal cortex were significantly correlated with clinical characteristics (BIS-11 scores, CCS abuse duration) in CCSD. The LR classifier models demonstrated accuracy, sensitivity, specificity, precision, and AUC of 82.5%, 82.5%, 82.5%, 76.8%, and 82.5%.

CONCLUSIONS

These data demonstrate that abnormal functional connectome may be closely linked to clinical characteristics in CCSD. Functional connectome-based biomarkers can be a powerful tool for personalized diagnosis of CCSD in the future.

Gray matter alteration in heroin-dependent men: An atlas-based magnetic resonance imaging study

Previous imaging studies on heroin addiction have reported brain morphological alterations. However, the effects of heroin exposure on gray matter volume varied among different studies due to different factors such as substitution treatment or mandatory abstinence. Meanwhile, the relationship between gray matter and heroin use history remains unknown. Thirty-three male heroin-dependent (HD) individuals who are not under any substitution treatment or mandatory abstinence and 40 male healthy controls (HC) were included in this structural magnetic resonance imaging study. With an atlas-based approach, gray matter structures up to individual functional area were delineated, and the differences in their volumes between the HD and HC groups were analyzed. In addition, the relationship between gray matter volume and duration of heroin use was explored. The HD group demonstrated significantly lower cortical volume mainly in the prefrontal cortex and mesolimbic dopaminergic regions across different parcellation levels, whereas several visual and somatosensory cortical regions in the HD group had greater volume relative to the HC group at a more detailed parcellation level. The duration of heroin use was negatively correlated with the gray matter volume of prefrontal cortex. These findings suggest that heroin addiction be related to gray matter alteration and might be related to damage/maladaption of the inhibitory control, reward, visual, and somatosensory functions of the brain, although cognitive correlates are warranted in future study. In addition, the atlas-based morphology analysis is a potential tool to help researchers search biomarkers of heroin addiction.

Cognitive profiles in persons with opioid use disorder enrolled in methadone treatment

Cognitive impairment is common in persons with opioid use disorder and associated with poor treatment outcomes, including elevated risk for relapse. Much less is known about the underlying structure of these deficits and the possible presence of cognitive phenotypes. A total of 177 adults (average 42.2 years of age, 52.0% male, 65.5% Caucasian) enrolled in a methadone maintenance treatment program completed the NIH Toolbox as part of a larger project. Cluster analyses revealed a 2-cluster solution-persons with intact cognitive function in all domains (n = 93; Intact) and those with impairments on tests of attention and executive function (n = 83; Impaired). Follow-up analyses revealed that the Impaired group was slightly older, more likely to self-identify as a racial/ethnic minority, and less likely to report consuming alcohol four or more times per week. These findings suggest the existence of distinct cognitive profiles in persons with opioid use disorder and encourage further examination, particularly studies to examine the possible benefits of routine screening for cognitive impairment as part of substance use treatment.

Reduced Cortical Thickness in the Right Caudal Middle Frontal Is Associated With Symptom Severity in Betel Quid-Dependent Chewers

BACKGROUND

Findings from brain structural imaging studies on betel quid dependence have supported relations between betel quid chewing and alterations in gray matter volume and white matter integrity. However, the effect of betel quid chewing on cortical thickness and the link between cortical thickness and symptom severity remains unascertained.

METHODS

In this observational study, we compared cortical thickness measures from 24 male betel quid-dependent chewers with 27 male healthy controls. Using FreeSufer, we obtained three-dimensional T1-weighted images that were used to compute the thickness of the cerebral cortex throughout the cortical layer.

RESULTS

Compared to healthy controls, betel quid dependent chewers displayed significant decreased cortical thickness in the precuneus, entorhinal, right paracentral, middle temporal, and caudal middle frontal gyri. Betel quid dependence scale scores negatively correlated (r = -0.604; p = 0.002) with reduced cortical thickness in the right caudal middle frontal of betel quid-dependent chewers.

CONCLUSION

The findings provide evidence for cortical thickness abnormality in betel dependent chewers and further propose that the severity of betel quid symptoms may be a critical aspect associated with the cortical alterations. The observed alterations may serve as potential mechanisms to explain why BQ chewing behavior is persistent among individuals with betel quid dependence.

Cortical surface morphology in long-term cannabis users: A multi-site MRI study

Cannabis exerts its psychoactive effect through cannabinoid receptors that are widely distributed across the cortical surface of the human brain. It is suggested that cannabis use may contribute to structural alterations across the cortical surface. In a large, multisite dataset of 120 controls and 141 cannabis users, we examined whether differences in key characteristics of the cortical surface - including cortical thickness, surface area, and gyrification index were related to cannabis use characteristics, including (i) cannabis use vs. non-use, (ii) cannabis dependence vs. non-dependence vs. non-use, and (iii) early adolescent vs. late adolescent onset of cannabis use vs. non-use. Our results revealed that cortical morphology was not associated with cannabis use, dependence, or onset age. The lack of effect of regular cannabis use, including problematic use, on cortical structure in our study is contrary to previous evidence of cortical morphological alterations (particularly in relation to cannabis dependence and cannabis onset age) in cannabis users. Careful reevaluation of the evidence on cannabis-related harm will be necessary to address concerns surrounding the long-term effects of cannabis use and inform policies in a changing cannabis regulation climate.

Associations Between Drinking and Cortical Thickness in Younger Adult Drinkers: Findings From the Human Connectome Project

BACKGROUND

Previous neuroimaging studies examining relations between alcohol misuse and cortical thickness have revealed that increased drinking quantity and alcohol-related problems are associated with thinner cortex. Although conflicting regional effects are often observed, associations are generally localized to frontal regions (e.g., dorsolateral prefrontal cortex [DLPFC], inferior frontal gyrus [IFG], and anterior cingulate cortex). Inconsistent findings may be attributed to methodological differences, modest sample sizes, and limited consideration of sex differences.

METHODS

This study examined neuroanatomical correlates of drinking quantity and heavy episodic drinking in a large sample of younger adults (N = 706; Mage  = 28.8; 51% female) using magnetic resonance imaging data from the Human Connectome Project. Exploratory analyses examined neuroanatomical correlates of executive function (flanker task) and working memory (list sorting).

RESULTS

Hierarchical linear regression models (controlling for age, sex, education, income, smoking, drug use, twin status, and intracranial volume) revealed significant inverse associations between drinks in past week and frequency of heavy drinking and cortical thickness in a majority of regions examined. The largest effect sizes were found for frontal regions (DLPFC, IFG, and the precentral gyrus). Follow-up regression models revealed that the left DLPFC was uniquely associated with both drinking variables. Sex differences were also observed, with significant effects largely specific to men.

CONCLUSIONS

This study adds to the understanding of brain correlates of alcohol use in a large, gender-balanced sample of younger adults. Although the cross-sectional methodology precludes causal inferences, these findings provide a foundation for rigorous hypothesis testing in future longitudinal investigations.

Region-Specific Changes of Insular Cortical Thickness in Heavy Smokers

Insula plays an essential role in maintaining the addiction to cigarette smoking and smoking-related alterations on the insular volume and density have been reported in smokers. However, less is known about the effects of chronic cigarette smoking on the insular cortical thickness. In this study, we explored the region-specific changes of insular cortical thickness in heavy smokers and their relations with smoking-related variables. 37 heavy smokers (29 males, mean age 47.19 ± 7.22 years) and 37 non-smoking healthy controls (29 males, mean age 46.95 ± 8.45 years) participated in the study. Subregional insular cortical thickness was evaluated and compared between the two groups. Correlation analysis was performed to investigate relationships between the insular cortical thickness and clinical characteristics in heavy smokers. There was no statistical difference on the cortical thickness in the left insula (p = 0.536) between the two groups while heavy smokers had a slightly thinner cortical thickness in the right insula (p = 0.048). In addition, heavy smokers showed a greater cortical thinning in the anterior (p = 0.0084) and superior (p = 0.0054) segment of the circular sulcus of the right insula as well as the inferior (p = 0.012) segment of the circular sulcus of the left insula. Moreover, the cortical thickness of the superior segment of the circular sulcus of the left insula was correlated negatively with nicotine severity (r = −0.423; p = 0.009) and the longer cigarette exposure was associated with the cortical thinning in the long insular gyrus and central sulcus of the right insula (r = −0.475; p = 0.003). Our findings indicate that chronic cigarette use is associated with region-specific insular thinning, which has the potential to improve our understanding of the specific roles of insular subregions in nicotine addiction.

Females are more vulnerable to Internet gaming disorder than males: Evidence from cortical thickness abnormalities

BACKGROUND

Male predominance is a well-known feature of Internet gaming disorder (IGD), with a reported male to female ratio of 3:1. Because of the overwhelming focus on males, little is known about the neural basis of sex differences in IGD, especially neuroanatomical features. Thus, investigations on sex differences with an adequate sample size are critical for improving the understanding of biological mechanisms underlying IGD.

METHODS

Structural magnetic resonance imaging data were acquired from 62 IGD subjects (29 males, 33 females) and 71 recreational game users (RGUs) (37 males, 34 females) with well-matched age and education levels. Group-by-sex interaction in cortical thickness was analyzed, and the correlations between cortical thickness and addiction severity were calculated.

RESULTS

We detected a group-by-sex interaction in the bilateral rostral middle frontal gyri (MFG), left superior frontal gyrus (SFG), left supramarginal gyrus (SMG), right posterior cingulate cortex (PCC), and right superior parietal lobule (SPL). Post-hoc analyses revealed that, compared with same-sex RGUs, male IGD subjects had increased cortical thickness and female IGD subjects had reduced cortical thickness beside their right PCC. By contrast, male IGD subjects had reduced cortical thickness and female IGD subjects had increased cortical thickness in their right PCC. Moreover, only females showed significant negative correlations between the cortical thickness and their self-reported cravings and Internet addiction test scores.

CONCLUSIONS

For female IGD subjects, the reduced cortical thickness, combined with the negative correlations of addiction severities, suggests the great effect created by IGD in the brain regions. Males and females may be affected differently by IGD, with females being more vulnerable to it.

Forging Neuroimaging Targets for Recovery in Opioid Use Disorder

The United States is in the midst of an opioid epidemic and lacks a range of successful interventions to reduce this public health burden. Many individuals with opioid use disorder (OUD) consume drugs to relieve physical and/or emotional pain, a pattern that may increasingly result in death. The field of addiction research lacks a comprehensive understanding of physiological and neural mechanisms instantiating this cycle of Negative Reinforcement in OUD, resulting in limited interventions that successfully promote abstinence and recovery. Given the urgency of the opioid crisis, the present review highlights faulty brain circuitry and processes associated with OUD within the context of the Three-Stage Model of Addiction (1). This model underscores Negative Reinforcement processes as crucial to the maintenance and exacerbation of chronic substance use together with Binge/Intoxication and Preoccupation/Anticipation processes. This review focuses on cross-sectional as well as longitudinal studies of relapse and treatment outcome that employ magnetic resonance imaging (MRI), functional near-infrared spectroscopy (fNIRs), brain stimulation methods, and/or electroencephalography (EEG) explored in frequency and time domains (the latter measured by event-related potentials, or ERPs). We discuss strengths and limitations of this neuroimaging work with respect to study design and individual differences that may influence interpretation of findings (e.g., opioid use chronicity/recency, comorbid symptoms, and biological sex). Lastly, we translate gaps in the OUD literature, particularly with respect to Negative Reinforcement processes, into future research directions involving operant and classical conditioning involving aversion/stress. Overall, opioid-related stimuli may lessen their hold on frontocingulate mechanisms implicated in Preoccupation/Anticipation as a function of prolonged abstinence and that degree of frontocingulate impairment may predict treatment outcome. In addition, longitudinal studies suggest that brain stimulation/drug treatments and prolonged abstinence can change brain responses during Negative Reinforcement and Preoccupation/Anticipation to reduce salience of drug cues, which may attenuate further craving and relapse. Incorporating this neuroscience-derived knowledge with the Three-Stage Model of Addiction may offer a useful plan for delineating specific neurobiological targets for OUD treatment.

Potential gray matter unpruned in adolescents and young adults dependent on dextromethorphan-containing cough syrups: evidence from cortical and subcortical study

Adolescence is a unique period in neurodevelopment. Dextromethorphan (DXM)-containing cough syrups are new addictive drugs used by adolescents and young adults. The effects of chronic DXM abuse on neurodevelopment in adolescents and young adults are still unknown. The aim of this study was to investigate the differences in cortical thickness and subcortical gray matter volumes between DXM-dependent adolescents and young adults and healthy controls, and to explore relationships between alternations in cortical thickness/subcortical volume and DXM duration, initial age of DXM use, as well as impulsive behavior in DXM-dependent adolescents and young adults. Thirty-eight DXM-dependent adolescents and young adults and 18 healthy controls underwent magnetic resonance imaging scanning, and cortical thickness across the continuous cortical surface was compared between the groups. Subcortical volumes were compared on a structure-by-structure basis. DXM-dependent adolescents and young adults exhibited significantly increased cortical thickness in the bilateral precuneus (PreC), left dorsal lateral prefrontal cortex (DLPFC. L), left inferior parietal lobe (IPL. L), right precentral gyrus (PreCG. R), right lateral occipital cortex (LOC. R), right inferior temporal cortex (ITC. R), right lateral orbitofrontal cortex (lOFC. R) and right transverse temporal gyrus (TTG. R) (all p < 0.05, multiple comparison corrected) and increased subcortical volumes of the right thalamus and right pallidum. There was a significant correlation between initial age of DXM use and cortical thickness of the DLPFC. L and PreCG. R. A significant correlation was also found between cortical thickness of the DLPFC. L and impulsive behavior in patients. This was the first study to explore relationships between cortical thickness/subcortical volume and impulsive behavior in adolescents dependent on DXM. These structural changes might explain the neurobiological mechanism of impulsive behavior in adolescent DXM users.

Cortical thickness and volume abnormalities in Internet gaming disorder: Evidence from comparison of recreational Internet game users

Although online gaming may lead to Internet gaming disorder (IGD), most players are recreational game users (RGUs) who do not develop IGD. Thus far, little is known about brain structural abnormalities in IGD subjects relative to RGUs. The inclusion of RGUs as a control group could minimize the potential effects of gaming experience and gaming-related cue familiarity on the neural mechanism of IGD subjects. In this study, structural magnetic resonance imaging data were acquired from 38 IGD subjects and 66 RGUs with comparable age, gender, and educational level. Group differences in cortical thickness and volume were analyzed using the FreeSurfer software. Correlations between cortical changes and addiction severity were calculated for both groups. Compared with the RGU group, the IGD group showed significantly decreased cortical thickness in the left lateral orbitofrontal cortex, inferior parietal lobule, bilateral cuneus, precentral gyrus, and right middle temporal gyrus. Moreover, significantly reduced cortical volume was observed in the left superior temporal gyrus and right supramarginal gyrus in the IGD group. Whole-brain correlational analysis indicated different correlations between the two groups. The brain regions that showed group differences were considered to be involved in cognitive control, decision making, and reward/loss processing. These functions may serve as potential mechanisms that explain why IGD individuals experience negative outcomes in frequent game playing.

Altered gray matter volume and disrupted functional connectivity of dorsolateral prefrontal cortex in men with heroin dependence

AIM

Chronic heroin use can cause various neuropathological characteristics that may compromise brain function. The present study evaluated the alteration of gray matter volume (GMV) and its resting-state functional connectivity (rsFC) over the dorsolateral prefrontal cortex (DLPFC) among male heroin users.

METHODS

Thirty heroin-dependent men undergoing methadone maintenance therapy and 30 educational-level- and age-matched male controls were recruited for this study. To assess their GMV and rsFC, the participants were evaluated using spoiled gradient echo and gradient-recalled echo planar imaging sequences with a 3-Tesla General Electric MR scanner under resting state.

RESULTS

The heroin-dependent men showed lower GMV over the right DLPFC in comparison with the controls. Further evaluation of the rsFC of the right DLPFC revealed a marked decrease in interhemispheric DLPFC connectivity among those with heroin dependence under control of head movement and GMV of the right DLPFC.

CONCLUSION

Although the mechanism remains unclear, the present study shows that chronic heroin use is associated with alteration of morphology as well as rsFC over the right DLPFC. As the DLPFC plays an imperative role in various domains of cognitive function, service providers for heroin users should consider the impacts of possible DLPFC-related cognitive deficits on treatment effectiveness.

Regional cerebral blood flow in opiate dependence relates to substance use and neuropsychological performance

Neuroimaging of opiate-dependent individuals indicates both altered brain structure and function. Magnetic resonance-based arterial spin labeling has been used to measure noninvasively cerebral blood flow (i.e. perfusion) in alcohol, tobacco and stimulant dependence; only one arterial spin labeling paper in opiate-dependent individuals demonstrated frontal and parietal perfusion deficits. Additional research on regional brain perfusion in opiate dependence and its relationship to cognition and self-regulation (impulsivity, risk taking and decision making) may inform treatment approaches for opiate-dependent individuals. Continuous arterial spin labeling magnetic resonance imaging at 4 T and neuropsychological measures assessed absolute brain perfusion levels, cognition and self-regulation in 18 cigarette smoking opiate-dependent individuals (sODI) stable on buprenorphine maintenance therapy. The sODI were compared with 20 abstinent smoking alcohol-dependent individuals (a substance-dependent control group), 35 smoking controls and 29 nonsmoking controls. sODI had lower perfusion in several cortical and subcortical regions including regions within the brain reward/executive oversight system compared with smoking alcohol-dependent individuals and nonsmoking controls. Perfusion was increased in anterior cingulate cortex and globus pallidus of sODI. Compared with all other groups, sODI had greater age-related declines in perfusion in most brain reward/executive oversight system and some other regions. In sODI, lower regional perfusion related to greater substance use, higher impulsivity and weaker visuospatial skills. Overall, sODI showed cortical and subcortical hypoperfusion and hyperperfusion. Relating to neuropsychological performance and substance use quantities, the frontal perfusion alterations are clinically relevant and constitute potential targets for pharmacological and cognitive-based therapeutic interventions to improve treatment outcome in opiate dependence.

Radiation-induced abnormal cortical thickness in patients with nasopharyngeal carcinoma after radiotherapy

Conventional MRI studies showed that radiation-induced brain necrosis in patients with nasopharyngeal carcinoma (NPC) in years after radiotherapy (RT) could involve brain gray matter (GM) and impair brain function. However, it is still unclear the radiation-induced brain morphological changes in NPC patients with normal-appearing GM in the early period after RT. In this study, we acquired high-resolution brain structural MRI data from three groups of patients, 22 before radiotherapy (pre-RT) NPC patients with newly diagnosed but not yet medically treated, 22 NPC patients in the early-delayed stage after radiotherapy (post-RT-ED), and 20 NPC patients in the late-delayed stage after radiotherapy (post-RT-LD), and then analyzed the radiation-induced cortical thickness alteration in NPC patients after RT. Using a vertex-wise surface-based morphometry (SBM) approach, we detected significantly decreased cortical thickness in the precentral gyrus (PreCG) in the post-RT-ED group compared to the pre-RT group. And the post-RT-LD group showed significantly increased cortical thickness in widespread brain regions, including the bilateral inferior parietal, left isthmus of the cingulate, left bank of the superior temporal sulcus and left lateral occipital regions, compared to the pre-RT group, and in the bilateral PreCG compared to the post-RT-ED group. Similar analysis with ROI-wise SBM method also found the consistent results. These results indicated that radiation-induced brain injury mainly occurred in the post-RT-LD group and the cortical thickness alterations after RT were dynamic in different periods. Our findings may reflect the pathogenesis of radiation-induced brain injury in NPC patients with normal-appearing GM and an early intervention is necessary for protecting GM during RT.

Disrupted white matter structural connectivity in heroin abusers

Neurocognitive impairment is one of the factors that put heroin abusers at greater risk for relapse, and deficits in related functional brain connections have been found. However, the alterations in structural brain connections that may underlie these functional and neurocognitive impairments remain largely unknown. In the present study, we investigated topological organization alterations in the structural network of white matter in heroin abusers and examined the relationships between the network changes and clinical measures. We acquired diffusion tensor imaging datasets from 76 heroin abusers and 78 healthy controls. Network-based statistic was applied to identify alterations in interregional white matter connectivity, and graph theory methods were used to analyze the properties of global networks. The participants also completed a battery of neurocognitive measures. One increased subnetwork characterizing widespread abnormalities in structural connectivity was present in heroin users, which mainly composed of default-mode, attentional and visual systems. The connection strength was positively correlated with increases in fractional anisotropy in heroin abusers. Intriguingly, the changes in within-frontal and within-temporal connections in heroin abusers were significantly correlated with daily heroin dosage and impulsivity scores, respectively. These findings suggest that heroin abusers have extensive abnormal white matter connectivity, which may mediate the relationship between heroin dependence and clinical measures. The increase in white matter connectivity may be attributable to the inefficient microstructure integrity of white matter. The present findings extend our understanding of cerebral structural disruptions that underlie neurocognitive and functional deficits in heroin addiction and provide circuit-level markers for this chronic disorder.

Frontal Metabolite Concentration Deficits in Opiate Dependence Relate to Substance Use, Cognition, and Self-Regulation

OBJECTIVE

Proton magnetic resonance spectroscopy (1H MRS) in opiate dependence showed abnormalities in neuronal viability and glutamate concentration in the anterior cingulate cortex (ACC). Metabolite levels in dorsolateral prefrontal cortex (DLPFC) or orbitofrontal cortex (OFC) and their neuropsychological correlates have not been investigated in opiate dependence.

METHODS

Single-volume proton MRS at 4 Tesla and neuropsychological testing were conducted in 21 opiate-dependent individuals (OD) on buprenorphine maintenance therapy. Results were compared to 28 controls (CON) and 35 alcohol-dependent individuals (ALC), commonly investigated treatment-seekers providing context for OD evaluation. Metabolite concentrations were measured from ACC, DLPFC, OFC and parieto-occipital cortical (POC) regions.

RESULTS

Compared to CON, OD had lower concentrations of N-acetylaspartate (NAA), glutamate (Glu), creatine +phosphocreatine (Cr) and myo-Inositol (mI) in the DLPFC and lower NAA, Cr, and mI in the ACC. OD, ALC, and CON were equivalent on metabolite levels in the POC and γ-aminobutyric acid (GABA) concentration did not differ between groups in any region. In OD, prefrontal metabolite deficits in ACC Glu as well as DLPFC NAA and choline containing metabolites (Cho) correlated with poorer working memory, executive and visuospatial functioning; metabolite deficits in DLPFC Glu and ACC GABA and Cr correlated with substance use measures. In the OFC of OD, Glu and choline-containing metabolites were elevated and lower Cr concentration related to higher nonplanning impulsivity. Compared to 3 week abstinent ALC, OD had significant DLPFC metabolite deficits.

CONCLUSION

The anterior frontal metabolite profile of OD differed significantly from that of CON and ALC. The frontal lobe metabolite abnormalities in OD and their neuropsychological correlates may play a role in treatment outcome and could be explored as specific targets for improved OD treatment.

Abnormal gray matter volume and resting-state functional connectivity in former heroin-dependent individuals abstinent for multiple years

Previous studies have suggested that heroin addiction is associated with structural and functional brain abnormalities. However, it is largely unknown whether these characteristics of brain abnormalities would be persistent or restored after long periods of abstinence. Considering the very high rates of relapse, we hypothesized that there may exist some latent neural vulnerabilities in abstinent heroin users. In this study, structural and resting-state functional magnetic resonance imaging data were collected from 30 former heroin-dependent (FHD) subjects who were drug free for more than 3 years and 30 non-addicted control (CN) volunteers. Voxel-based morphometry was used to identify possible gray matter volume differences between the FHD and CN groups. Alterations in resting-state functional connectivity in FHD were examined using brain areas with gray matter deficits as seed regions. Significantly reduced gray matter volume was observed in FHD in an area surrounding the parieto-occipital sulcus, which included the precuneus and cuneus. Functional connectivity analyses revealed that the FHD subjects showed reduced positive correlation within the default mode network and visual network and decreased negative correlation between the default mode network, visual network and task positive network. Moreover, the altered functional connectivity was correlated with self-reported impulsivity scores in the FHD subjects. Our findings suggest that disruption of large-scale brain systems is present in former heroin users even after multi-year abstinence, which could serve as system-level neural underpinnings for behavioral dysfunctions associated with addiction.

Brain Imaging in Gambling Disorder

Gambling disorder recently was reclassified under the category “substance-related and addictive disorders.” With regard to the diagnostic criteria, it overlaps a great deal with substance use disorder, i.e., loss of control, craving/withdrawal, and neglect of other areas of life. However, the gambling disorder symptom “chasing one’s losses” is the only criterion absent from substance use disorder. Therefore, special forms of reward (i.e., gain/loss) processing, such as the processing of loss avoidance and loss aversion, have just recently attracted attention among gambling disorder researchers. Because gambling disorder might be considered an addiction in its “pure” form, i.e., without the influence of a drug of abuse, investigating brain volume changes in people with this behavioral addiction is an important task for neuroimaging researchers in exploring the neural signatures of addiction. Because the brain is a complex network, investigation of alterations in functional connectivity has gained interest among gambling disorder researchers in order to get a more complete picture of functional brain changes in people with gambling disorder. However, only a few studies on brain structure and functional connectivity in gambling disorder have been performed so far. This review focuses on brain imaging studies of reward and loss processing, with an emphasis on loss avoidance and aversion as well as brain volume and functional connectivity in gambling disorder.

ZNF804A rs1344706 is associated with cortical thickness, surface area, and cortical volume of the unmedicated first episode schizophrenia and healthy controls

The effects of ZNF804A rs1344706, a prominent susceptibility gene for schizophrenia, on gray matter (GM) structure in unmedicated schizophrenia (SZ) patients are still unknown, although several previous studies investigated the effects in medicated SZ patients and healthy controls (HC). Analyzing cortical thickness, surface area, and GM volume simultaneously may provide a more precise and complete picture of the effects. We genotyped 59 unmedicated first episode SZ patients and 60 healthy controls for the ZNF804A single nucleotide polymorphism (SNP) rs1344706, and examined between-group differences in cortical thickness, surface area, and cortical volume using a full-factorial 2 × 2 analysis of variance (ANOVA). We found the risk allele (T) in ZNF804A rs1344706, compared to the non-risk allele (G), was associated with thinner cortex in the bilateral precuneus, left precentral gyrus, and several other regions, associated with a smaller cortical surface area in the left superior parietal, precuneus cortex and left superior frontal, and associated with a lower cortical volume in the left superior frontal, left precentral, and right precuneus in SZ patients. In contrast, in the controls, the T allele was associated with the increased cortical measurements compared to the G allele in the same regions as those mentioned above. ZNF804A rs1344706 has significant, but different, effects on cortical thickness, surface area, and cortical volume in multiple regions of the brain cortex. Our findings suggest that ZNF804A rs1344706 may aggravate the risk for schizophrenia by exerting its effects on cortical thickness, surface area, and cortical volume in these brain regions.

Clinically Combating Reward Deficiency Syndrome (RDS) with Dopamine Agonist Therapy as a Paradigm Shift: Dopamine for Dinner?

Everyday, there are several millions of people that are increasingly unable to combat their frustrating and even fatal romance with getting high and/or experiencing “normal” feelings of well-being. In the USA, the FDA has approved pharmaceuticals for drug and alcohol abuse: tobacco and nicotine replacement therapy. The National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) remarkably continue to provide an increasing understanding of the intricate functions of brain reward circuitry through sophisticated neuroimaging and molecular genetic applied technology. Similar work is intensely investigated on a worldwide basis with enhanced clarity and increased interaction between not only individual scientists but across many disciplines. However, while it is universally agreed that dopamine is a major neurotransmitter in terms of reward dependence, there remains controversy regarding how to modulate its role clinically to treat and prevent relapse for both substance and non-substance-related addictive behaviors. While the existing FDA-approved medications promote blocking dopamine, we argue that a more prudent paradigm shift should be biphasic—short-term blockade and long-term upregulation, enhancing functional connectivity of brain reward circuits.