Shallow discounting of delayed cocaine by male rhesus monkeys when immediate food is the choice alternative

Mechanisms of impulsive choice: Experiments to explore and models to map the empirical terrain

Impulsive choice is preference for a smaller-sooner (SS) outcome over a larger-later (LL) outcome when LL choices result in greater reinforcement maximization. Delay discounting is a model of impulsive choice that describes the decaying value of a reinforcer over time, with impulsive choice evident when the empirical choice-delay function is steep. Steep discounting is correlated with multiple diseases and disorders. Thus, understanding the processes underlying impulsive choice is a popular topic for investigation. Experimental research has explored the conditions that moderate impulsive choice, and quantitative models of impulsive choice have been developed that elegantly represent the underlying processes. This review spotlights experimental research in impulsive choice covering human and nonhuman animals across the domains of learning, motivation, and cognition. Contemporary models of delay discounting designed to explain the underlying mechanisms of impulsive choice are discussed. These models focus on potential candidate mechanisms, which include perception, delay and/or reinforcer sensitivity, reinforcement maximization, motivation, and cognitive systems. Although the models collectively explain multiple mechanistic phenomena, there are several cognitive processes, such as attention and working memory, that are overlooked. Future research and model development should focus on bridging the gap between quantitative models and empirical phenomena.

Choice between food and cocaine or fentanyl reinforcers under fixed and variable schedules in female and male rhesus monkeys

RATIONALE

Illicit drugs may be unpredictable in terms of the time and effort required to obtain them, and this can be modeled with variable- (VR) vs. fixed-ratio (FR) schedules. In a recent experiment (Zamarripa et al. 2023), the potency of cocaine to maintain choice was greatest under a VR (compared with a FR) when food was available under a FR schedule.

OBJECTIVES

The goal of the current study was to extend prior choice results with VR vs. FR schedules to a more efficient procedure with cocaine or fentanyl vs. food. Furthermore, the FR schedule of food delivery was manipulated to determine whether increased drug choice under a VR (compared with a FR) schedule depends on the size of the schedule of nondrug reinforcement.

METHODS

Adult female (n = 2) and male (n = 4) monkeys chose between cocaine (0-30 µg/kg/injection) or fentanyl (0-1.0 µg/kg/injection) and food (2 pellets/delivery) under a 5-component procedure. In different conditions, food was available under a FR 25, 50, or 100 and cocaine or fentanyl were available under FR or VR 100 schedules.

RESULTS

Cocaine's potency to maintain choice was greatest under a VR 100 (compared with FR 100) when food was available under a FR 50 or 100, and fentanyl's potency to maintain choice was generally greatest under a VR 100 (compared with FR 100) when food was available under a FR 25 or 100. However, outcomes between FR and VR schedules with fentanyl were less robust compared with cocaine.

CONCLUSION

Variability in the time and effort required to obtain illicit drugs could contribute to excessive allocation of behavior toward drug use at the expense of more predictable nondrug alternatives, supporting treatment or policies aimed at making drug access more predictable through agonist medications or a safe supply. The impact of variable requirements on drug choice may be reduced if nondrug reinforcers are relatively less costly, supporting the use of low-cost reinforcers in behavioral therapies like contingency management.

Delay discounting as a behavioral phenotype associated with social rank in female and male cynomolgus monkeys: Correlation with kappa opioid receptor availability

Cocaine use disorder (CUD) is a significant problem worldwide, with no FDA-approved treatments. Epidemiological data indicate that only about 17 % of people that use cocaine will meet DSM criteria for CUD. Thus, the identification of biomarkers predictive of eventual cocaine use may be of great value. Two potentially useful predictors of CUD are social hierarchies in nonhuman primates and delay discounting. Both social rank and preference for a smaller, immediate reinforcer relative to a larger, delayed reinforcer have been predictive of CUD. Therefore, we wanted to determine if there was also a relationship between these two predictors of CUD. In the present study, monkeys cocaine-naive responded under a concurrent schedule of 1- vs. 3-food pellets and delivery of the 3-pellet option was delayed. The primary dependent variable was the indifference point (IP), which is the delay that results in 50 % choice for both options. In the initial determination of IP, there were no differences based on sex or social rank of the monkeys. When the delays were redetermined after ~25 baseline sessions (range 5-128 sessions), dominant females and subordinate males showed the largest increases in IP scores from the first determination to the second. Because 13 of these monkeys had prior PET scans of the kappa opioid receptor (KOR), we examined the relationship between KOR availability and IP values and found that the change in IP scores from the first to the second determination significantly negatively predicted average KOR availability in most brain regions. Future studies will examine acquisition to cocaine self-administration in these same monkeys, to determine if IP values are predictive of vulnerability to cocaine reinforcement.

Choice between food and cocaine reinforcers under fixed and variable schedules in female and male rhesus monkeys

Illicit drugs like cocaine may be uncertain in terms of the time and effort required to obtain them. Behavior maintained by variable schedules resembles excessive drug-taking compared with fixed schedules. However, no prior research has examined fixed versus variable schedules in drug versus nondrug choice. The present study evaluated cocaine versus food choice under fixed- (FR) and variable-ratio (VR) schedules. The simpler food versus food and cocaine versus cocaine arrangements also were included. Adult female (n = 6) and male (n = 7) rhesus monkeys chose between cocaine (0.01-0.18 mg/kg/injection) and food (4 pellets/delivery), food and food (4 pellets/delivery), or cocaine and cocaine (0.018-0.03 mg/kg/injection) under FR and VR 100 and 200 schedules. In cocaine versus food choice, cocaine's potency to maintain choice was greatest when available under a VR 100 or 200 schedule and food under an FR schedule and was lowest when cocaine was available under an FR 200 schedule and food was available under a VR 200 schedule. In food versus food choice, males chose food associated with a VR schedule more than food associated with an FR schedule. In cocaine versus cocaine choice, females and males chose cocaine associated with a VR schedule more than cocaine associated with an FR schedule, particularly under VR 200. These findings suggest that uncertainty in terms of time and effort required to obtain cocaine, or perhaps the occasional low-cost access that results from VR schedules, results in greater allocation of behavior toward drug reinforcers at the expense of more certain, nondrug alternatives. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Discounting of outcomes in which immediate gains are followed by delayed losses

Previous discounting research has focused on relatively simple situations (e.g., choosing between immediate and delayed gains, or between immediate and delayed losses) and the relations among amount, delay, and subjective value in such situations are now well established. Many everyday choice situations, however, are more complex, involving alternatives that combine gains and losses. In two experiments, participants discounted a monetary outcome that combined an immediate gain with a delayed loss. Consistent with the discounting framework, the value of the combination was approximately equal to the difference between the (undiscounted) value of the immediate gain and the (discounted) value of the delayed loss. More precise predictions of the relative subjective value of the delayed loss component of a combination were given by the same hyperboloid function that describes discounting in simple choice situations where outcomes only involve gains or losses, not both. As in previous studies, when the outcome was a simple one consisting of only a delayed loss, discounting was not affected by the amount of that loss. Surprisingly, however, when the loss was preceded by a gain, the degree to which the combination was discounted was affected by the amount of the loss. Notably, discounting of the delayed loss component of the combination decreased with the amount of the loss in a fashion similar to that observed with simple delayed gains, where smaller amounts are discounted more steeply than larger amounts. Choice situations involving immediate gains followed by delayed losses pose iconic self-control problems, and the present findings support the application of the discounting framework to these important everyday problems.

Qualitative variations in delay discounting: A brief review and future directions

The discounting paradigm has been challenged by an increasing number of studies presenting qualitative variations in the individual discount function. Particularly, the subjective value of a loss does not necessarily systematically decrease with delay to the outcome. Qualitative variation refers to variations in shape rather than steepness of the discount function, such as positive discounting, zero discounting, unsystematic discounting, and negative discounting. Data from three previous studies were analysed in terms of qualitative variations observed in delay discounting patterns. Attention was also given to methods used and to the relationship between the results from the various levels of investigation. We found qualitative differences between discounting of monetary gains and losses on an individual level. While discounting of gains mainly took the form of conventional positive discounting, discounting of losses often took the form of zero discounting or unsystematic discounting. Further, there were more qualitative variations in discounting of both gains and losses among adolescents compared to adults. By examining verbal reports and single choices, we identified some of the rules and consequences involved in these delay discounting patterns. The different rules and consequences observed for the gain and loss scenarios, support that discounting of gains and losses may involve different combinations of reinforcing contingencies. These results point towards a possible way to explain the influences of qualitative variations in delay discounting.

A method for studying reinforcement factors controlling impulsive choice for use in behavioral neuroscience

Although procedures originating within the experimental analysis of behavior commonly are used in behavioral neuroscience to produce behavioral endpoints, they are used less often to analyze the behavioral processes involved, particularly at the level of individual organisms (see Soto, 2020). Concurrent-chains procedures have been used extensively to study choice and to quantify relations between various dimensions of reinforcement and preference. Unfortunately, parametric analysis of those relations using traditional steady-state, single-subject experimental designs can be time-consuming, often rendering these procedures impractical for use in behavioral neuroscience. The purpose of this paper is to describe how concurrent-chains procedures can be adapted to allow for parametric examination of effects of the reinforcement dimensions involved in impulsive choice (magnitude and delay) within experimental sessions in rats. Data are presented indicating that this procedure can produce relatively consistent within-session estimates of sensitivity to reinforcement in individual subjects, and that these estimates can be modified by neurobiological manipulation (drug administration). These data suggest that this type of procedure offers a promising approach to the study of neurobiological mechanisms of complex behavior in individual organisms, which could facilitate a more fruitful relationship between behavior analysis and behavioral neuroscience.

A review of cross-commodity delay discounting research with relevance to addiction

Delay discounting (DD) refers to the decrease in the subjective value of a reward as the delay to its receipt increases. As high rates of DD are consistently associated with measures of substance misuse, DD is an important construct in current conceptualizations of addiction. High rates of DD appear to model preference for the immediate rewards provided by substance use, resulting in the interpretation that individuals with substance use disorder are generally unable or unwilling to delay gratification to obtain larger but delayed rewards. This interpretation is largely based on literature implementing binary choice tasks using differing amounts of the same commodity (i.e., single-commodity), in which high rates of DD can result from relative preference for the immediate outcome or relative dispreference for the delayed outcome. We propose that tasks using different commodities (i.e., cross-commodity) for the immediate and delayed outcomes offer potential in disentangling these dissociable and consequentially distinct interpretations. Our review suggests that cross-commodity DD tasks provide unique insights into understanding addiction not captured by single-commodity designs. We conclude that more research implementing cross-commodity DD tasks is needed to better understand the role of intertemporal choice in addiction and recovery.

Quantification of observable behaviors induced by typical and atypical kappa-opioid receptor agonists in male rhesus monkeys

RATIONALE

Kappa-opioid receptor (KOR) agonists are antinociceptive but have side effects that limit their therapeutic utility. New KOR agonists have been developed that are fully efficacious at the KOR but may produce fewer or reduced side effects that are typical of KOR agonists.

OBJECTIVES

We determined behavioral profiles for typical and atypical KOR agonists purported to differ in intracellular-signaling profiles as well as a mu-opioid receptor (MOR) agonist, oxycodone, using a behavioral scoring system based on Novak et al. (Am J Primatol 28:124-138, 1992, Am J Primatol 46:213-227, 1998) and modified to quantify drug-induced effects (e.g., Duke et al. J Pharmacol Exp Ther 366:145-157, 2018).

METHODS

Six adult male rhesus monkeys were administered a range of doses of the typical KOR agonists, U50-488H (0.0032-0.1 mg/kg) and salvinorin A (0.00032-0.01 mg/kg); the atypical KOR agonists, nalfurafine (0.0001-0.001 mg/kg) and triazole 1.1 (0.01-0.32 mg/kg); the MOR agonist, oxycodone (0.0032-0.32 mg/kg); and as controls, cocaine (0.032-0.32 mg/kg) and ketamine (0.32-10 mg/kg). For time-course determinations, the largest dose of each KOR agonist or MOR agonist was administered across timepoints (10-320 min). In mixture conditions, oxycodone (0.1 mg/kg) was followed by KOR-agonist administration.

RESULTS

Typical KOR agonists produced sedative-like and motor-impairing effects. Nalfurafine was similar to typical KOR agonists on most outcomes, and triazole 1.1 produced no effects on its own except for reducing scratch during time-course determinations. In the mixture, all KOR agonists reduced oxycodone-induced scratching, U50-488H and nalfurafine reduced species-typical activity, and U50-488H increased rest/sleep posture.

CONCLUSIONS

Atypical "biased" KOR agonists produce side-effect profiles that are relatively benign (triazole 1.1) or reduced (nalfurafine) compared to typical KOR agonists.

Unpredictability as a modulator of drug self-administration: Relevance for substance-use disorders

Drug self-administration has been regarded as a gold-standard preclinical model of addiction and substance-use disorder (SUD). However, investigators are becoming increasingly aware, that certain aspects of addiction or SUDs experienced by humans are not accurately captured in our preclinical self-administration models. The current review will focus on two such aspects of current preclinical drug self-administration models: 1) Predictable vs. unpredictable drug access in terms of the time and effort put into obtaining drugs (i.e., response requirement) and drug quality (i.e., amount) and 2) rich vs. lean access to drugs. Some behavioral and neurobiological mechanisms that could contribute to excessive allocation of behavior toward drug-seeking and drug-taking at the expense of engaging in nondrug-related activities are discussed, and some directions for future research are identified. Based on the experiments reviewed, lean and unpredictable drug access could worsen drug-seeking and drug-taking behavior in individuals with SUDs. Once more fully explored, this area of research will help determine whether and how unpredictable and lean cost requirements affect drug self-administration in preclinical laboratory studies with nonhuman subjects and will help determine whether incorporating these conditions in current self-administration models will increase their predictive validity.

Kappa opioid agonists reduce oxycodone self-administration in male rhesus monkeys

RATIONALE

Combinations of mu and kappa opioid receptor (KOR) agonists have been proposed as potential analgesic formulations with reduced abuse liability. The current studies extend previous work by investigating the typical KOR agonist, salvinorin A, and the atypical KOR agonist, nalfurafine, as deterrents of oxycodone self-administration using a progressive ratio (PR) schedule of reinforcement.

METHODS

In separate experiments, adult male rhesus monkeys (N = 4/experiment) were trained under a PR schedule of reinforcement to self-administer cocaine (0.1 mg/kg/injection) and saline on alternating days. Oxycodone (0.01-0.1 mg/kg/injection) alone and combined with salvinorin A (experiment 1; 0.006, 0.012 mg/kg/injection) or nalfurafine (experiment 2; 0.0001-0.00032 mg/kg/injection) were tested within the alternating cocaine and saline baseline. The mechanism of nalfurafine's effects on oxycodone self-administration was investigated via pretreatment with the KOR antagonist, nor-binaltorphimine (nor-BNI; 10 mg/kg; i.m.).

RESULTS

All subjects self-administered oxycodone alone above saline levels at sufficiently large doses, and combining salvinorin A or nalfurafine with oxycodone reduced the mean number of injections per session to saline levels (experiment 1) or to levels that were significantly lower than oxycodone alone (experiment 2). The ability of nalfurafine to reduce oxycodone self-administration was reversed by pretreatment with nor-BNI.

CONCLUSIONS

These results demonstrate that KOR agonists, including the clinically used KOR agonist, nalfurafine, can punish self-administration of a prescription opioid analgesic, oxycodone, in rhesus monkeys and that nalfurafine's punishing effect is KOR-dependent. Combinations of KOR agonists with prescription opioids may have reduced abuse liability.

On the Complexity of Discounting, Choice Situations, and People

Although steep delay discounting is associated with various behavioral problems, perhaps most prominently substance abuse, we argue that it is best not conceived of as a character flaw such as impulsivity. Such a view, although part of a centuries-old tradition, does not distinguish between actions whose outcomes involve gains and losses, or between delayed outcomes and probabilistic outcomes, nor does it acknowledge that how steeply an individual discounts one of these kinds of outcome appears to be independent of how steeply they discount other kinds. Therefore, we advocate an approach that does not require making judgments about the character of the individuals involved. We show that when drug-dependent individuals are compared with controls, a substantial number of the drug-dependent individuals discount delayed monetary rewards less steeply than the average (median) member of the control group. Moreover, a substantial number of the controls discount more steeply than the average drug-dependent individual. Finally, we point out that many everyday choice situations differ from those studied in most discounting experiments in that they involve both gains and losses as well as qualitatively different outcomes that may be both delayed and probabilistic. Past research on discounting that focused on simple choice situations has provided a solid foundation, but research on more complicated situations is now needed. We believe that the principles revealed by such research will both inform the choices of treatment providers and improve our understanding of the complicated decisions that people face every day.

Trying to make sense of rodents' drug choice behavior

Since the first experimental hint for the existence of "an actual desire or striving for the drug" in nonhuman animals by Sidney Spragg in the late 1930s, much effort has been expended by lab researchers to try to model in a valid manner the key behavioral aspects and signs of addiction in animals, typically in rodents (i.e., mainly rats and, to a lesser extent, mice). Despite much advances, there still remains a lingering doubt about the disordered status of drug use in rodents. This is mainly because drug use occurs in a particular setting where animals have access to a drug for self-administration but without access to other valuable behavioral options that could compete with and divert from drug use. Here I review evidence showing that enriching the drug setting with other behavioral options can dramatically influence the pattern of drug choices in rodents. Overall, access to other options during drug access can divert the vast majority of rats from continued drug use. Only few individuals continue to engage in drug use despite access to and at the expense of other options. However, there exist certain high-risk settings in which virtually all animals are vulnerable to develop a harmful pattern of exclusive drug use that can even become fatal in the long run if not discontinued by an outside intervention. Paradoxically, it appears that the behavioral trait that is hypothesized to uniquely render rodents vulnerable to the latter settings (i.e., a narrow focus on the local, current choice, with no consideration of the global pattern of choice) would also protect most of them from using drugs in other choice settings. I conclude with an attempt to make sense of this peculiar setting-specific behavior and with some general propositions for future research.

The effect of economy type on demand and preference for cocaine and saccharin in rats

BACKGROUND

Economy type is an important determinant of reinforcer value. This study investigated the effect of open and closed economies on demand and preference for cocaine and saccharin in rats.

METHODS

In the first phase, rats were trained to lever press for cocaine infusions or saccharin. The number of presses required for each reinforcer increased across sessions. Cocaine and saccharin economy type was manipulated over groups by varying post-session availability of these reinforcers. One group of rats had three hours' post-session access to unlimited cocaine (open economy). A second group had three hours' post-session access to unlimited saccharin. A third group had no post-session access to either reinforcer (closed economy). In a second phase, rats in the three conditions could make mutually exclusive choices for cocaine or saccharin.

RESULTS

Post-session access to saccharin caused saccharin demand to become more elastic. Post-session access to cocaine had no effect on demand for cocaine but made demand for saccharin more elastic. Results from the choice phase generally paralleled those from the demand phase, the main finding being that post-session saccharin access caused an increase in cocaine preference.

CONCLUSIONS

These results show that manipulating economy type can affect cocaine and non-drug reinforcers differently. Opening the saccharin economy decreased saccharin's value. Opening the cocaine economy did not decrease cocaine's value, but instead led to a devaluation of saccharin. These results suggest that cocaine choice may be determined not only by the reinforcers immediately available, but also by those reinforcers' broader contexts of availability.

Pharmacotherapies for decreasing maladaptive choice in drug addiction: Targeting the behavior and the drug

Drug addiction can be conceptualized as a disorder of maladaptive decision making in which drugs are chosen at the expense of pro-social, nondrug alternatives. The study of decision making in drug addiction has focused largely on the role of impulsivity as a facilitator of addiction, in particular the tendency for drug abusers to choose small, immediate gains over larger but delayed outcomes (i.e., delay discounting). A parallel line of work, also focused on decision making in drug addiction, has focused on identifying the determinants underlying the choice to take drugs over nondrug alternatives (i.e., drug vs. nondrug choice). Both tracks of research have been valuable tools in the development of pharmacotherapies for treating maladaptive decision making in drug addiction, and a number of common drugs have been studied in both designs. However, we have observed that there is little uniformity in the administration regimens of potential treatments between the designs, which hinders congruence in the development of single treatment strategies to reduce both impulsive behavior and drug choice. The current review provides an overview of the drugs that have been tested in both delay-discounting and drug-choice designs, and focuses on drugs that reduced the maladaptive choice in both designs. Suggestions to enhance congruence between the findings in future studies are provided. Finally, we propose the use of a hybridized, experimental approach that may enable researchers to test the effectiveness of therapeutics at decreasing impulsive and drug choice in a single design.

Remifentanil maintains lower initial delayed nonmatching-to-sample accuracy compared to food pellets in male rhesus monkeys

Emerging human laboratory and preclinical drug self-administration data suggest that a history of contingent abused drug exposure impairs performance in operant discrimination procedures, such as delayed nonmatching-to-sample (DNMTS), that are hypothesized to assess components of executive function. However, these preclinical discrimination studies have exclusively used food as the reinforcer and the effects of drugs as reinforcers in these operant procedures are unknown. The present study determined effects of contingent intravenous remifentanil injections on DNMTS performance hypothesized to assess 1 aspect of executive function, working memory. Daily behavioral sessions consisted of 2 components with sequential intravenous remifentanil (0, 0.01-1.0 μg/kg/injection) or food (0, 1-10 pellets) availability in nonopioid dependent male rhesus monkeys (n = 3). Remifentanil functioned as a reinforcer in the DNMTS procedure. Similar delay-dependent DNMTS accuracy was observed under both remifentanil- and food-maintained components, such that higher accuracies were maintained at shorter (0.1-1.0 s) delays and lower accuracies approaching chance performance were maintained at longer (10-32 s) delays. Remifentanil maintained significantly lower initial DNMTS accuracy compared to food. Reinforcer magnitude was not an important determinant of DNMTS accuracy for either remifentanil or food. These results extend the range of experimental procedures under which drugs function as reinforcers. Furthermore, the selective remifentanil-induced decrease in initial DNMTS accuracy is consistent with a selective impairment of attentional, but not memorial, processes. (PsycINFO Database Record

Utility of Nonhuman Primates in Substance Use Disorders Research

Substance use disorders (i.e., drug addiction) constitute a global and insidious public health issue. Preclinical biomedical research has been invaluable in elucidating the environmental, biological, and pharmacological determinants of drug abuse and in the process of developing innovative pharmacological and behavioral treatment strategies. For more than 70 years, nonhuman primates have been utilized as research subjects in biomedical research related to drug addiction. There are already several excellent published reviews highlighting species differences in both pharmacodynamics and pharmacokinetics between rodents and nonhuman primates in preclinical substance abuse research. Therefore, the aim of this review is to highlight three advantages of nonhuman primates as preclinical substance abuse research subjects. First, nonhuman primates offer technical advantages in experimental design compared to other laboratory animals that afford unique opportunities to promote preclinical-to-clinical translational research. Second, these technical advantages, coupled with the relatively long lifespan of nonhuman primates, allows for pairing longitudinal drug self-administration studies and noninvasive imaging technologies to elucidate the biological consequences of chronic drug exposure. Lastly, nonhuman primates offer advantages in the patterns of intravenous drug self-administration that have potential theoretical implications for both the neurobiological mechanisms of substance use disorder etiology and in the drug development process of pharmacotherapies for substance use disorders. We conclude with potential future research directions in which nonhuman primates would provide unique and valuable insights into the abuse of and addiction to novel psychoactive substances.

Choice between variable and fixed cocaine injections in male rhesus monkeys

RATIONALE

The schedule of drug availability may enhance choice of a drug. In non-human subjects, reinforcers are chosen more often when available under variable schedules of reinforcement relative to fixed schedules.

OBJECTIVE

To determine whether variable-drug access is an important determinant of cocaine choice by manipulating the schedule, drug dose, and combination of schedule + dose.

METHOD

Four male rhesus monkeys chose between cocaine doses (0.025-0.4 mg/kg/injection). In control conditions, the schedule and dose of each drug delivery were fixed. In other conditions, the reinforcement schedule (i.e., variable-ratio schedule), dose of each cocaine delivery, or both were variable on one lever while all aspects on the other lever remained fixed.

RESULTS

When cocaine dose was equal on average (0.1 mg/kg/injection), 2 of 4 subjects chose cocaine associated with the variable schedule more than the fixed schedule. All subjects chose the variable dose that was equal on average to the fixed dose, and this difference was statistically significant. Three of 4 subjects chose cocaine associated with the variable combination over the fixed option (when the dose was equal on average). During dose-response determinations (when dose on the variable and fixed options were not equal), making the schedule, dose, or both variable generally did not alter cocaine's potency as a reinforcer.

CONCLUSION

While many factors contribute to drug choice, unpredictable drug access is a feature that may be common in the natural environment and could play a key role in the allocation of behavior to drug alternatives by patients with substance-use disorders.