Enhanced midbrain response at 6-month follow-up in cocaine addiction, association with reduced drug-related choice

Neurovascular effects of cocaine: relevance to addiction

Cocaine is a highly addictive drug, and its use is associated with adverse medical consequences such as cerebrovascular accidents that result in debilitating neurological complications. Indeed, brain imaging studies have reported severe reductions in cerebral blood flow (CBF) in cocaine misusers when compared to the brains of healthy non-drug using controls. Such CBF deficits are likely to disrupt neuro-vascular interaction and contribute to changes in brain function. This review aims to provide an overview of cocaine-induced CBF changes and its implication to brain function and to cocaine addiction, including its effects on tissue metabolism and neuronal activity. Finally, we discuss implications for future research, including targeted pharmacological interventions and neuromodulation to limit cocaine use and mitigate the negative impacts.

Candidate biomarkers in psychiatric disorders: state of the field

The field of psychiatry is hampered by a lack of robust, reliable and valid biomarkers that can aid in objectively diagnosing patients and providing individualized treatment recommendations. Here we review and critically evaluate the evidence for the most promising biomarkers in the psychiatric neuroscience literature for autism spectrum disorder, schizophrenia, anxiety disorders and post-traumatic stress disorder, major depression and bipolar disorder, and substance use disorders. Candidate biomarkers reviewed include various neuroimaging, genetic, molecular and peripheral assays, for the purposes of determining susceptibility or presence of illness, and predicting treatment response or safety. This review highlights a critical gap in the biomarker validation process. An enormous societal investment over the past 50 years has identified numerous candidate biomarkers. However, to date, the overwhelming majority of these measures have not been proven sufficiently reliable, valid and useful to be adopted clinically. It is time to consider whether strategic investments might break this impasse, focusing on a limited number of promising candidates to advance through a process of definitive testing for a specific indication. Some promising candidates for definitive testing include the N170 signal, an event-related brain potential measured using electroencephalography, for subgroup identification within autism spectrum disorder; striatal resting-state functional magnetic resonance imaging (fMRI) measures, such as the striatal connectivity index (SCI) and the functional striatal abnormalities (FSA) index, for prediction of treatment response in schizophrenia; error-related negativity (ERN), an electrophysiological index, for prediction of first onset of generalized anxiety disorder, and resting-state and structural brain connectomic measures for prediction of treatment response in social anxiety disorder. Alternate forms of classification may be useful for conceptualizing and testing potential biomarkers. Collaborative efforts allowing the inclusion of biosystems beyond genetics and neuroimaging are needed, and online remote acquisition of selected measures in a naturalistic setting using mobile health tools may significantly advance the field. Setting specific benchmarks for well-defined target application, along with development of appropriate funding and partnership mechanisms, would also be crucial. Finally, it should never be forgotten that, for a biomarker to be actionable, it will need to be clinically predictive at the individual level and viable in clinical settings.

Recovery of inhibitory control prefrontal cortex function in inpatients with heroin use disorder: a 15-week longitudinal fMRI study

Importance

Heroin addiction and related mortality impose a devastating toll on society, with little known about the neurobiology of this disease or its treatment. Poor inhibitory control is a common manifestation of prefrontal cortex (PFC) impairments in addiction, and its potential recovery following treatment is largely unknown in heroin (or any drug) addiction.

Objective

To study inhibitory control brain activity in iHUD and HC, before and after 15 weeks of inpatient treatment in the former.

Design

A longitudinal cohort study (11/2020-03/2022) where iHUD and HC underwent baseline and follow-up fMRI scans. Average follow-up duration: 15 weeks.

Setting

The iHUD and HC were recruited from treatment facilities and surrounding neighborhoods, respectively.

Participants

Twenty-six iHUD [40.6±10.1 years; 7 (29.2%) women] and 24 age-/sex-matched HC [41.1±9.9 years; 9 (37.5%) women].

Intervention

Following the baseline scan, inpatient iHUD continued to participate in a medically-assisted program for an average of 15 weeks (abstinence increased from an initial 183±236 days by 65±82 days). The HC were scanned at similar time intervals.

Main Outcomes and Measures

Behavioral performance as measured by the stop-signal response time (SSRT), target detection sensitivity (d', proportion of hits in go vs. false-alarms in stop trials), and brain activity (blood-oxygen level dependent signal differences) during successful vs. failed stops in the stop signal task.

Results

As we previously reported, at time 1 and as compared to HC, iHUD exhibited similar SSRT but impaired d' [t(38.7)=2.37, p=.023], and lower anterior and dorsolateral PFC (aPFC, dlPFC) activity (p<.001). Importantly, at time 2, there were significant gains in aPFC and dlPFC activity in the iHUD (group*session interaction, p=.002); the former significantly correlated with increases in d' specifically in iHUD (p=.012).

Conclusions and Relevance

Compared to HC, the aPFC and dlPFC impairments in the iHUD at time 1 were normalized at time 2, which was associated with individual differences in improvements in target detection sensitivity. For the first time in any drug addiction, these results indicate a treatment-mediated inhibitory control brain activity recovery. These neurobehavioral results highlight the aPFC and dlPFC as targets for intervention with a potential to enhance self-control recovery in heroin addiction.

Simulated opioid choice linked to opioid use disorder severity among veterans with chronic pain: initial validation of a novel paradigm

Background: Modeling addictive behavior among individuals with, or at risk for, opioid use disorder (OUD) in a way that is accurate, ethical, and reproducible presents a pressing concern. OUD risk is elevated among people with chronic pain on long-term opioid therapy (LTOT).Objectives: To provide initial validation of a novel opioid preference task as an index of OUD and its symptomatology among veterans prescribed opioids for chronic pain, a population at high risk for poor opioid-related outcomes. The relative ease by which such a paradigm can be implemented and performed in clinical contexts, including enabling investigation of opioid reinforcement and drug-seeking behavior while avoiding ethical pitfalls associated with direct drug administration, could make this task an attractive approach for potentially tracking OUD symptoms.Methods: We studied 87 veterans (74 males, 13 females) on LTOT for chronic pain - 33 of whom had OUD diagnoses. Participants completed a picture-viewing choice task to assess preference for viewing opioid-related images in comparison with standardized pleasant, unpleasant, neutral, and blank images. Opioid-related choice, measured by vigor of button pressing, was tested for association with OUD severity (measured by symptom counts), as well as craving and anhedonia.Results: Choice for opioid-related images was positively correlated with OUD severity (i.e., number of DSM-5 measured OUD symptoms) (r = 0.38, p < .001), particularly among those meeting diagnostic criteria for OUD (r = 0.47, p = .006). Neither craving nor anhedonia correlated with opioid-related choice.Conclusions: Our results provide initial validation for a new opioid picture-choice paradigm in patients with chronic pain.

Structural and functional brain recovery in individuals with substance use disorders during abstinence: A review of longitudinal neuroimaging studies

BACKGROUND

Neuroimaging studies reveal structural and functional including neurochemical brain abnormalities in individuals with substance use disorders compared to healthy controls. However, whether and to what extent such dysfunction is reversible with abstinence remains unclear, and a review of studies with longitudinal within-subject designs is lacking. We performed a systematic review of longitudinal neuroimaging studies to explore putative brain changes associated with abstinence in treatment-seeking individuals with substance use disorders.

METHODS

Following PRISMA guidelines, we examined articles published up to May 2021 that employed a neuroimaging technique and assessed neurobiological recovery in treatment-seeking participants at a minimum of two time-points separated by a period of abstinence (longer than 24 h apart) or significant reduction in drug use.

RESULTS

Forty-five studies met inclusion criteria. Encouragingly, in this limited but growing literature, the majority of studies demonstrated at least partial neurobiological recovery with abstinence. Structural recovery appeared to occur predominantly in frontal cortical regions, the insula, hippocampus, and cerebellum. Functional and neurochemical recovery was similarly observed in prefrontal cortical regions but also in subcortical structures. The onset of structural recovery appears to precede neurochemical recovery, which begins soon after cessation (particularly for alcohol); functional recovery may require longer periods of abstinence.

CONCLUSIONS

The literature is still growing and more studies are warranted to better understand abstinence-mediated neural recovery in individuals with substance use disorders. Elucidating the temporal dynamics between neuronal recovery and abstinence will enable evidence-based planning for more effective and targeted treatment of substance use disorders, potentially pre-empting relapse.

Longitudinal changes in network engagement during cognitive control in cocaine use disorder

BACKGROUND

Cocaine use disorder (CUD) is characterized by poor cognitive control and has limited empirically supported treatment options. Furthermore, an understanding of brain mechanisms underlying CUD is at a relatively early stage. Thus, this study aimed to investigate longitudinal alterations in functional neural networks associated with cognitive control in cocaine use disorder (CUD).

METHODS

Secondary analysis was performed on data from 44 individuals who participated in three randomized clinical trials for CUD and completed an fMRI Stroop task both at baseline and post-treatment. Independent component analysis (ICA) was performed to assess changes in functional network engagement and investigate associations with cocaine-use behaviors. Mixed linear models were performed to test for longitudinal effects on network engagement and relationships with baseline patterns of cocaine use (i.e., past-month frequency and lifetime years of use) and periods of abstinence/use between scans (i.e., percent negative urine toxicology and maximum days of contiguous abstinence).

RESULTS

Six functional networks were identified as being related to cognitive control and/or exhibiting changes in engagement following treatment. Results indicated that engagement of amygdala-striatal, middle frontal and right-frontoparietal networks were reduced over time in CUD. Less change in the amygdala-striatal network was associated with greater lifetime years of cocaine use. Additional analyses revealed that negative toxicology results and achievement of continuous abstinence were associated with greater engagement of the right-frontoparietal network.

CONCLUSIONS

Neural systems that underlie cognitive control may change over time in individuals with CUD. A longer history of cocaine-use may hinder changes in network activity, potentially impeding recovery.

Alteration of neuroinflammation detected by 18F-GE180 PET imaging in place-conditioned rats with morphine withdrawal

BACKGROUND

Accumulating evidence indicates that neuroinflammation (NI) significantly contributes to drug addiction, but the conversion of NI after drug withdrawal is not clear. Here, we conducted ¹⁸F-flutriciclamide (GE180) positron emission tomography (PET) imaging to investigate the conversion of NI during drug withdrawal and conditioning-induced aversion by measuring the change in microglial activation with ¹⁸F-GE180.

METHODS

Twelve male adult Sprague-Dawley rats were subjected to morphine withdrawal by the administration of naloxone, and six of them were used to model conditioned place aversion (CPA). ¹⁸F-GE180 PET imaging was performed for 11 rats on the last day of the morphine treatment phase and for 10 rats on the response assessment phase of the behavior conditioning procedure. A ¹⁸F-GE180 template was established for spatial normalization of each individual image, and the differential ¹⁸F-GE180 uptakes between the drug withdrawal (DW) group and the drug addiction (DA) group, the CPA group and the DA group, and the CPA group and the DW group were compared by a voxel-wise two-sample t test using SPM8.

RESULTS

Both the DW group and the CPA group spent less time in the conditioning cage during the post-test phase compared with the pretest phase, but only the difference in the CPA group was significant (63.2 ± 34.6 vs. - 159.53 ± 22.02, P < 0.005). Compared with the DA group, the uptake of ¹⁸F-GE180 increased mainly in the hippocampus, visual cortex, thalamus and midbrain regions and decreased mainly in the sensory-related cortices after the administration of naloxone in both the DW and CPA groups. Increased ¹⁸F-GE180 uptake was only observed in the mesolimbic regions after conditioned aversion compared with the DW group.

CONCLUSION

In morphine-dependent rats, Neuroinflammation (NI) became more severe in the addiction-involved brain regions but remitted in the sensory-related brain regions after the administration of naloxone, and this NI induced by withdrawal was further aggravated after conditioned aversion formation thus may help to consolidate the withdrawal memory.

Altered neural activities during response inhibition in adults with addiction: a voxel-wise meta-analysis

BACKGROUND

Previous literature has extensively investigated the brain activity during response inhibition in adults with addiction. Inconsistent results including both hyper- and hypo-activities in the fronto-parietal network (FPN) and the ventral attention network (VAN) have been found in adults with addictions, compared with healthy controls (HCs).

METHODS

Voxel-wise meta-analyses of abnormal task-evoked regional activity were conducted for adults with substance dependence (SD) and behavioral addiction during response inhibition tasks to solve previous inconsistencies. Twenty-three functional magnetic resonance imaging studies including 479 substance users, 38 individuals with behavioral addiction and 494 HCs were identified.

RESULTS

Compared with HCs, all addictions showed hypo-activities in regions within FPN (inferior frontal gyrus and supramarginal gyrus) and VAN (inferior frontal gyrus, middle temporal gyrus, temporal pole and insula), and hyper-activities in the cerebellum during response inhibition. SD subgroup showed almost the same activity patterns, with an additional hypoactivation of the precentral gyrus, compared with HCs. Stronger activation of the cerebellum was associated with longer addiction duration for adults with SD. We could not conduct meta-analytic investigations into the behavioral addiction subgroup due to the small number of datasets.

CONCLUSION

This meta-analysis revealed altered activation of FPN, VAN and the cerebellum in adults with addiction during response inhibition tasks using non-addiction-related stimuli. Although FPN and VAN showed lower activity, the cerebellum exhibited stronger activity. These results may help to understand the neural pathology of response inhibition in addiction.

Effects of attentional bias modification therapy on the cue reactivity and cognitive control networks in participants with cocaine use disorders

BACKGROUND

While attentional bias modification therapy (ABMT) alters drug-related behaviors in some substance users, results have been mixed in individuals with cocaine use disorders (CUD).

OBJECTIVES

The current study examined whether ABMT affected brain functioning during independent measures of cue reactivity (i.e., cocaine versus food cues) and cognitive control (i.e., incongruent versus congruent trials), and whether brain activity was associated with baseline or post-intervention cocaine use.

METHODS

37 participants (62% male) were randomly assigned to ABMT or control therapy. Clinical and neuroimaging assessments occurred at baseline and immediately post-intervention, with additional clinical testing at 2 weeks and 3 months following intervention. Cocaine use was assessed through self-report.

RESULTS

Slower reaction times and increased functional activation (prefrontal cortex, posterior parietal cortex) were observed for incongruent versus congruent stimuli and increased functional activation for cocaine relative to food videos (ventral striatum, dorsolateral prefrontal cortex and orbitofrontal cortex). The default-mode network (DMN) was not deactivated during exposure to cocaine videos. The degree of activation during cocaine relative to food cues was associated with baseline cocaine use (insula only) and reduction in use following treatment (insula and anterior DMN) above and beyond clinical variables. Cognitive control network activity was not associated with cocaine use at baseline or following treatment. ABMT therapy did not differentially affect cocaine use or functional activation during either task.

CONCLUSION

Current results suggest a relationship between cue reactivity network activation and cocaine use, but question the efficacy of ABMT in changing brain function during cue reactivity or cognitive control tasks.

The neural interface between negative emotion regulation and motivation for change in cocaine dependent individuals under treatment

BACKGROUND

Emotion regulation is important for cocaine addiction treatment success, particularly during early abstinence. In addition, the neural underpinnings of emotion processing overlap with those of motivation and goal-directed behavior. We examined if the neural underpinnings of emotion maintenance and its regulation correlate with cocaine treatment motivation.

METHODS

Forty-five cocaine dependent individuals (CDIs) starting outpatient treatment in a public specialized addiction treatment clinic in Granada (Spain) underwent fMRI scans while performing a Reappraisal task, and completed the University of Rhode Island Change Assessment Scale (URICA), to measure treatment motivation. We conducted correlation analyses to examine the association between emotion maintenance and regulation related brain activation and URICA's Readiness to Change scores. We also explored links between Emotional reports during the fMRI reappraisal task, duration of abstinence, and anxiety and depression symptoms.

RESULTS

Readiness to Change scores were positively correlated with activations in the right dorsolateral prefrontal and right parietal cortices, the midbrain (p ≤ 0.001, cluster extents ≥109 voxels), and basolateral amygdala (P_FWE-SVC<0.05), while negatively with emotion maintenance related activation in the same cortical areas and activations in the dorsomedial frontal cortex, the nucleus accumbens and the left fusiform gyrus. Emotional reactivity negatively correlated with right dorsolateral prefrontal cortex reappraisal related activation (r= -0.40, p = 0.007), and the Regulate score positively correlated with the left fusiform gyrus emotion maintenance related activation (r = 0.31, p = 0.04).

CONCLUSIONS

Emotional related activation in frontoparietal, accumbens, fusiform, amygdala and midbrain regions engaged during emotion regulation and its maintenance correlate with early treatment motivation in CDIs.

Bouncing back: Brain rehabilitation amid opioid and stimulant epidemics

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Frontoparietal event related potentials predict/track recovery.

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Frontostriatal functional magnetic resonance imaging signals predict/track recovery.

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Transcranial magnetic left prefrontal stimulation reduces craving and drug use.

Recent methamphetamine and opioid use epidemics are a major public health concern. Chronic stimulant and opioid use are characterized by significant psychosocial, physical and mental health costs, repeated relapse, and heightened risk of early death. Neuroimaging research highlights deficits in brain processes and circuitry that are linked to responsivity to drug cues over natural rewards as well as suboptimal goal-directed decision-making. Despite the need for interventions, little is known about (1) how the brain changes with prolonged abstinence or as a function of various treatments; and (2) how symptoms change as a result of neuromodulation. This review focuses on the question: What do we know about changes in brain function during recovery from opioids and stimulants such as methamphetamine and cocaine? We provide a detailed overview and critique of published research employing a wide array of neuroimaging methods – functional and structural magnetic resonance imaging, electroencephalography, event-related potentials, diffusion tensor imaging, and multiple brain stimulation technologies along with neurofeedback – to track or induce changes in drug craving, abstinence, and treatment success in stimulant and opioid users. Despite the surge of methamphetamine and opioid use in recent years, most of the research on neuroimaging techniques for recovery focuses on cocaine use. This review highlights two main findings: (1) interventions can lead to improvements in brain function, particularly in frontal regions implicated in goal-directed behavior and cognitive control, paired with reduced drug urges/craving; and (2) the targeting of striatal mechanisms implicated in drug reward may not be as cost-effective as prefrontal mechanisms, given that deep brain stimulation methods require surgery and months of intervention to produce effects. Overall, more studies are needed to replicate and confirm findings, particularly for individuals with opioid and methamphetamine use disorders.

Connectome-Based Prediction of Cocaine Abstinence

OBJECTIVE

The authors sought to identify a brain-based predictor of cocaine abstinence by using connectome-based predictive modeling (CPM), a recently developed machine learning approach. CPM is a predictive tool and a method of identifying networks that underlie specific behaviors ("neural fingerprints").

METHODS

Fifty-three individuals participated in neuroimaging protocols at the start of treatment for cocaine use disorder, and again at the end of 12 weeks of treatment. CPM with leave-one-out cross-validation was conducted to identify pretreatment networks that predicted abstinence (percent cocaine-negative urine samples during treatment). Networks were applied to posttreatment functional MRI data to assess changes over time and ability to predict abstinence during follow-up. The predictive ability of identified networks was then tested in a separate, heterogeneous sample of individuals who underwent scanning before treatment for cocaine use disorder (N=45).

RESULTS

CPM predicted abstinence during treatment, as indicated by a significant correspondence between predicted and actual abstinence values (r=0.42, df=52). Identified networks included connections within and between canonical networks implicated in cognitive/executive control (frontoparietal, medial frontal) and in reward responsiveness (subcortical, salience, motor/sensory). Connectivity strength did not change with treatment, and strength at posttreatment assessment also significantly predicted abstinence during follow-up (r=0.34, df=39). Network strength in the independent sample predicted treatment response with 64% accuracy by itself and 71% accuracy when combined with baseline cocaine use.

CONCLUSIONS

These data demonstrate that individual differences in large-scale neural networks contribute to variability in treatment outcomes for cocaine use disorder, and they identify specific abstinence networks that may be targeted in novel interventions.

Neural Correlates of Drug-Biased Choice in Currently Using and Abstinent Individuals With Cocaine Use Disorder

BACKGROUND

The choice for drugs over alternative reinforcers is a translational hallmark feature of drug addiction. The neural basis of such drug-biased choice is not well understood, particularly in individuals with protracted drug abstinence who cannot ethically participate in studies that offer drug-using opportunities.

METHODS

We developed a functional magnetic resonance imaging drug-choice task to examine the choice for viewing drug-related images, rather than for actually consuming a drug. Actively using (n = 18) and abstaining (n = 19) individuals with a history of cocaine use disorder (CUD: dependence or abuse) and matched healthy control subjects (n = 26) participated.

RESULTS

Individuals with CUD, especially those actively using cocaine outside the laboratory, made more choices than control subjects to view images depicting cocaine (especially when directly compared against images depicting an alternative appetitive reinforcer [food]). Functional magnetic resonance imaging data revealed that in individuals with CUD, the act of making drug-related choices engaged brain regions implicated in choice difficulty or ambivalence (i.e., dorsal anterior cingulate cortex, which was higher in all individuals with CUD than control subjects). Drug-related choices in CUD also engaged brain regions implicated in reward (e.g., midbrain/ventral tegmental area, which was most activated in active users, although this region was not hypothesized a priori).

CONCLUSIONS

These results help clarify the neural mechanisms underlying drug-biased choice in human addiction, which, beyond mechanisms involved in value assignment or reward, may critically involve mechanisms that contribute to resolving difficult decisions. Future studies are needed to validate these behavioral and neural abnormalities as markers of drug seeking and relapse in treatment contexts.

Toward biomarkers of the addicted human brain: Using neuroimaging to predict relapse and sustained abstinence in substance use disorder

The ability to predict relapse is a major goal of drug addiction research. Clinical and diagnostic measures are useful in this regard, but these measures do not fully and consistently identify who will relapse and who will remain abstinent. Neuroimaging approaches have the potential to complement these standard clinical measures to optimize relapse prediction. The goal of this review was to survey the existing drug addiction literature that either used a baseline functional or structural neuroimaging phenotype to longitudinally predict a clinical outcome, or that examined test-retest of a neuroimaging phenotype during a course of abstinence or treatment. Results broadly suggested that, relative to individuals who sustained abstinence, individuals who relapsed had (1) enhanced activation to drug-related cues and rewards, but reduced activation to non-drug-related cues and rewards, in multiple corticolimbic and corticostriatal brain regions; (2) weakened functional connectivity of these same corticolimbic and corticostriatal regions; and (3) reduced gray and white matter volume and connectivity in prefrontal regions. Thus, beyond these regions showing baseline group differences, reviewed evidence indicates that function and structure of these regions can prospectively predict - and normalization of these regions can longitudinally track - important clinical outcomes including relapse and adherence to treatment. Future clinical studies can leverage this information to develop novel treatment strategies, and to tailor scarce therapeutic resources toward individuals most susceptible to relapse.

Prefrontal gray matter volume recovery in treatment-seeking cocaine-addicted individuals: a longitudinal study

Deficits in prefrontal cortical (PFC) function have been consistently reported in individuals with cocaine use disorders (iCUD), and have separately been shown to improve with longer-term abstinence. However, it is less clear whether the PFC structural integrity possibly underlying these deficits is also modulated by sustained reduction in drug use in iCUD. Here, T1-weighted magnetic resonance imaging scans were acquired, and performance on a neuropsychological test battery was assessed, in 19 initially abstinent treatment-seeking iCUD, first at baseline and then after six months of significantly reduced or no drug use (follow-up). A comparison cohort of 12 healthy controls was also scanned twice with a similar inter-scan interval. The iCUD showed increased gray matter volume in the left inferior frontal gyrus and bilaterally in the ventromedial prefrontal cortex at follow-up compared to baseline; healthy controls, as expected, showed no changes over this same time period. The iCUD also showed improved decision making and cognitive flexibility, with the latter correlated significantly with the gray matter volume increases in the inferior frontal gyrus. Given its association with improved cognitive function, the longitudinal recovery in cortical gray matter volume, particularly in regions where structure and function are adversely affected by chronic drug use, reflects a quantifiable positive impact of significantly reduced drug use on cortical structural integrity.

Functional neural changes following behavioral therapies and disulfiram for cocaine dependence

A growing literature exists on neural correlates of treatment outcome. However, different types-or components of-treatment have distinct theorized mechanisms of action. And it is not yet known how changes in neural activity across treatment relate to engagement in different treatment components. Participants with cocaine use disorders in a randomized clinical trial received cognitive-behavioral therapy (CBT) plus, in a 2 × 2 design, contingency management (CM) or no CM, and disulfiram or placebo. Participants performed a functional MRI Stroop task, a measure of cognitive control, at the beginning of and after the 12-week treatment. Analyses assessed changes in Stroop-related neural activity within the sample overall and assessed how changes in Stroop-related activity correlated with measures of treatment process specific to each form of treatment (i.e., participation in CBT sessions, receipt of CM prizes, administration of disulfiram pills). Within the sample overall, compared with beginning of treatment, posttreatment Stroop-related neural activity was diminished in the hippocampus, thalamus, cingulate, precentral, post- and precentral gyrus, and precuneus and culmen regions (pFWE < .05). In separate whole-brain correlation analyses, greater reductions in Stroop-related activity were associated with more treatment engagement-"CBT sessions" with the precentral gyrus, inferior parietal lobule, and middle and medial frontal gyrus; "CM prizes" with the postcentral frontal gyrus. Disulfiram "medication days" were not associated with changes in Stroop-related activity. Findings suggest that key process indicators of CBT and CM may be associated with functional changes in cognitive-control-related neurocircuitry. (PsycINFO Database Record

Reduced activity in functional networks during reward processing is modulated by abstinence in cocaine addicts

Cocaine addiction is characterized by alterations in motivational and cognitive processes. Recent studies have shown that some alterations present in cocaine users may be related to the activity of large functional networks. The aim of this study was to investigate how these functional networks are modulated by non-drug rewarding stimuli in cocaine-dependent individuals. Twenty abstinent cocaine-dependent and 21 healthy matched male controls viewed erotic and neutral pictures while undergoing a functional magnetic resonance imaging scan. Group independent component analysis was then performed in order to investigate how functional networks were modulated by reward in cocaine addicts. The results showed that cocaine addicts, compared with healthy controls, displayed diminished modulation of the left frontoparietal network in response to erotic pictures, specifically when they were unpredicted. Additionally, a positive correlation between the length of cocaine abstinence and the modulation of the left frontoparietal network by unpredicted erotic images was found. In agreement with current addiction models, our results suggest that cocaine addiction contributes to reduce sensitivity to rewarding stimuli and that abstinence may mitigate this effect.

A preliminary study of longitudinal neuroadaptation associated with recovery from addiction

BACKGROUND

Few studies have explored longitudinal change in event-related brain responses during early recovery from addiction. Moreover, existing findings yield evidence of both increased and decreased signaling within reward and control centers over time. The current study explored reward- and control-related signals in a risky decision-making task and specifically investigated parametric modulations of the BOLD signal, rather than signal magnitude alone. It was hypothesized that risk-related signals during decision-making and outcome evaluation would reflect recovery and that change in specific signals would correspond with improved treatment outcomes.

METHODS

Twenty-one substance dependent individuals were recruited upon enrollment in community-based substance use treatment programs, wherein they received treatment-as-usual. Participants completed functional neuroimaging assessments at baseline and 3-month follow-up while performing the Balloon Analogue Risk Task (BART). Risk- and reward-sensitive signals were identified using parametric modulators. Substance use was tracked throughout the 3-month study interval using the timeline follow-back procedure.

RESULTS

Longitudinal contrasts of parametric modulators suggested improved formation of risk-informed outcome expectations at follow-up. Specifically, a greater response to high risk (low-likelihood) positive feedback was identified in caudal anterior cingulate cortex (ACC) and a greater response to low risk (low-likelihood) negative feedback was identified in caudal ACC and inferior frontal gyrus. In addition, attenuation of a ventromedial prefrontal cortex (vmPFC) "reward-seeking" signal (i.e., increasing response with greater reward) during risky decisions at follow-up was associated with less substance use during the study interval.

CONCLUSIONS

Changes in risk- and reward-related signaling in ACC/vmPFC appear to reflect recovery and may support sobriety.

Abnormal response to methylphenidate across multiple fMRI procedures in cocaine use disorder: feasibility study

RATIONALE

The indirect dopamine agonist methylphenidate remediates cognitive deficits in psychopathology, but the individual characteristics that determine its effects on the brain are not known.

OBJECTIVES

We aimed to determine whether targeted dopaminergically modulated traits and individual differences could predict neural response to methylphenidate across multiple functional magnetic resonance imaging (fMRI) procedures.

METHODS

We combined neural measures from three separate procedures (two inhibitory control tasks differing in their degree of emotional salience and resting-state functional connectivity) during methylphenidate (20 mg oral, versus randomized and counterbalanced placebo) and correlated these aggregated responses with cocaine use disorder diagnosis (22 cocaine abusers, 21 controls), symptoms of attention deficit hyperactivity disorder, and working memory capacity.

RESULTS

Cocaine abusers, relative to controls, had a lower response in the dorsolateral prefrontal cortex to methylphenidate across all three procedures, driven by responses to the two inhibitory control tasks; reduced methylphenidate fMRI response in this region further correlated with more frequent cocaine use.

CONCLUSIONS

Cocaine abuse (and its frequency), associated with lower tonic dopamine levels, correlated with a reduction in activation to methylphenidate (versus placebo). These initial results provide feasibility to the idea that multimodal fMRI tasks can be meaningfully aggregated, and that these aggregated procedures show a common disruption in addiction in a highly anticipated region relevant to cognitive control. Results also suggest that drug use frequency may represent an important modulatory variable in interpreting the efficacy of pharmacologically enhanced cognitive interventions in addiction.

Neurofunctional Reward Processing Changes in Cocaine Dependence During Recovery

Although reward processing appears altered in addiction, few studies track neurofunctional changes following treatment or relate these to measures of reduced drug use. The current study examined neurofunctional alterations in reward processing in cocaine dependence (CD) pretreatment and posttreatment to determine whether these changes relate to clinically meaningful outcome indicators. Treatment-seeking CD outpatients (N=29) underwent functional magnetic resonance imaging while performing a monetary incentive delay task (MIDT) pretreatment and posttreatment. The MIDT parses anticipatory from outcome phases of reward/loss processing. Abstinence indicators (negative urines, days abstinent from cocaine during follow-up) were collected throughout treatment and up to 1 year later. Healthy control (HC) participants (N=28) were also scanned twice with the MIDT. Relative to pretreatment, at posttreatment CD participants demonstrated increased anticipatory reward activity in the midbrain, thalamus, and precuneus (pFWE<0.05). Increased midbrain activity correlated with cocaine abstinence during the 1-year follow-up. Ventral striatal (VS) activity during loss anticipation correlated negatively with negative urine screens. HC group test-retest results showed decreased ventromedial prefrontal cortex activity during winning outcomes. CD-HC group-by-time differences revealed increased left inferior frontal gyrus activity in the CD group during anticipatory phases at posttreatment. In CD participants, increased posttreatment activity in dopamine-innervated regions suggests lowered thresholds in anticipatory signaling for non-drug rewards. Midbrain and VS responses may represent biomarkers associated with CD abstinence. Abstinence-related neurobiological changes occur in similar regions implicated during active use and may possibly be used to track progress during short- and long-term recovery.

Converging effects of cocaine addiction and sex on neural responses to monetary rewards

There is some evidence that cocaine addiction manifests as more severe in women than men. Here, we examined whether these sex-specific differences in the clinical setting parallel differential neurobehavioral sensitivity to rewards in the laboratory setting. Twenty-eight (14 females/14 males) cocaine-dependent and 25 (11 females/14 males) healthy individuals completed a monetary reward task during fMRI. Results showed that the effects of cocaine dependence and sex overlapped in regions traditionally considered part of the mesocorticolimbic brain circuits including the hippocampus and posterior cingulate cortex (PCC), as well as those outside of this circuit (e.g., the middle temporal gyrus). The nature of this 'overlap' was such that both illness and female sex were associated with lower activations in these regions in response to money. Diagnosis-by-sex interactions instead emerged in the frontal cortex, such that cocaine-dependent females exhibited lower precentral gyrus and greater inferior frontal gyrus (IFG) activations relative to cocaine-dependent males and healthy females. Within these regions modulated both by diagnosis and sex, lower activation in the hippocampus and PCC, and higher IFG activations, correlated with increased subjective craving during the task. Results suggest sex-specific differences in addiction extend to monetary rewards and may contribute to core symptoms linked to relapse.

Glucocorticoid Regulation of Food-Choice Behavior in Humans: Evidence from Cushing's Syndrome

The mechanisms by which glucocorticoids regulate food intake and resulting body mass in humans are not well-understood. One potential mechanism could involve modulation of reward processing, but human stress models examining effects of glucocorticoids on behavior contain important confounds. Here, we studied individuals with Cushing's syndrome, a rare endocrine disorder characterized by chronic excess endogenous glucocorticoids. Twenty-three patients with Cushing's syndrome (13 with active disease; 10 with disease in remission) and 15 controls with a comparably high body mass index (BMI) completed two simulated food-choice tasks (one with “explicit” task contingencies and one with “probabilistic” task contingencies), during which they indicated their objective preference for viewing high calorie food images vs. standardized pleasant, unpleasant, and neutral images. All participants also completed measures of food craving, and approximately half of the participants provided 24-h urine samples for assessment of cortisol and cortisone concentrations. Results showed that on the explicit task (but not the probabilistic task), participants with active Cushing's syndrome made fewer food-related choices than participants with Cushing's syndrome in remission, who in turn made fewer food-related choices than overweight controls. Corroborating this group effect, higher urine cortisone was negatively correlated with food-related choice in the subsample of all participants for whom these data were available. On the probabilistic task, despite a lack of group differences, higher food-related choice correlated with higher state and trait food craving in active Cushing's patients. Taken together, relative to overweight controls, Cushing's patients, particularly those with active disease, displayed a reduced vigor of responding for food rewards that was presumably attributable to glucocorticoid abnormalities. Beyond Cushing's, these results may have relevance for elucidating glucocorticoid contributions to food-seeking behavior, enhancing mechanistic understanding of weight fluctuations associated with oral glucocorticoid therapy and/or chronic stress, and informing the neurobiology of neuropsychiatric conditions marked by abnormal cortisol dynamics (e.g., major depression, Alzheimer's disease).

Noninvasive brain stimulation treatments for addiction and major depression

Major depressive disorder (MDD) and substance use disorders (SUDs) are prevalent, disabling, and challenging illnesses for which new treatment options are needed, particularly in comorbid cases. Neuroimaging studies of the functional architecture of the brain suggest common neural substrates underlying MDD and SUDs. Intrinsic brain activity is organized into a set of functional networks, of which two are particularly relevant to psychiatry. The salience network (SN) is crucial for cognitive control and response inhibition, and deficits in SN function are implicated across a wide variety of psychiatric disorders, including MDD and SUDs. The ventromedial network (VMN) corresponds to the classic reward circuit, and pathological VMN activity for drug cues/negative stimuli is seen in SUDs/MDD. Noninvasive brain stimulation (NIBS) techniques, including rTMS and tDCS, have been used to enhance cortico–striatal–thalamic activity through the core SN nodes in the dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, and anterior insula. Improvements in both MDD and SUD symptoms ensue, including in comorbid cases, via enhanced cognitive control. Inhibition of the VMN also appears promising in preclinical studies for quenching the pathological incentive salience underlying SUDs and MDD. Evolving techniques may further enhance the efficacy of NIBS for MDD and SUD cases that are unresponsive to conventional treatments.

Neuroscience of inhibition for addiction medicine: from prediction of initiation to prediction of relapse

A core deficit in drug addiction is the inability to inhibit maladaptive drug-seeking behavior. Consistent with this deficit, drug-addicted individuals show reliable cross-sectional differences from healthy nonaddicted controls during tasks of response inhibition accompanied by brain activation abnormalities as revealed by functional neuroimaging. However, it is less clear whether inhibition-related deficits predate the transition to problematic use, and, in turn, whether these deficits predict the transition out of problematic substance use. Here, we review longitudinal studies of response inhibition in children/adolescents with little substance experience and longitudinal studies of already addicted individuals attempting to sustain abstinence. Results show that response inhibition and its underlying neural correlates predict both substance use outcomes (onset and abstinence). Neurally, key roles were observed for multiple regions of the frontal cortex (e.g., inferior frontal gyrus, dorsal anterior cingulate cortex, and dorsolateral prefrontal cortex). In general, less activation of these regions during response inhibition predicted not only the onset of substance use, but interestingly also better abstinence-related outcomes among individuals already addicted. The role of subcortical areas, although potentially important, is less clear because of inconsistent results and because these regions are less classically reported in studies of healthy response inhibition. Overall, this review indicates that response inhibition is not simply a manifestation of current drug addiction, but rather a core neurocognitive dimension that predicts key substance use outcomes. Early intervention in inhibitory deficits could have high clinical and public health relevance.

Cocaine choice procedures in animals, humans, and treatment-seekers: Can we bridge the divide?

Individuals with cocaine use disorder chronically self-administer cocaine to the detriment of other rewarding activities, a phenomenon best modeled in laboratory drug-choice procedures. These procedures can evaluate the reinforcing effects of drugs versus comparably valuable alternatives under multiple behavioral arrangements and schedules of reinforcement. However, assessing drug-choice in treatment-seeking or abstaining humans poses unique challenges: for ethical reasons, these populations typically cannot receive active drugs during research studies. Researchers have thus needed to rely on alternative approaches that approximate drug-choice behavior or assess more general forms of decision-making, but whether these alternatives have relevance to real-world drug-taking that can inform clinical trials is not well-understood. In this mini-review, we (A) summarize several important modulatory variables that influence cocaine choice in nonhuman animals and non-treatment seeking humans; (B) discuss some of the ethical considerations that could arise if treatment-seekers are enrolled in drug-choice studies; (C) consider the efficacy of alternative procedures, including non-drug-related decision-making and 'simulated' drug-choice (a choice is made, but no drug is administered) to approximate drug choice; and (D) suggest opportunities for new translational work to bridge the current divide between preclinical and clinical research.

Predicting subsequent relapse by drug-related cue-induced brain activation in heroin addiction: an event-related functional magnetic resonance imaging study

Abnormal salience attribution is implicated in heroin addiction. Previously, combining functional magnetic resonance imaging (fMRI) and a drug cue-reactivity task, we demonstrated abnormal patterns of subjective response and brain reactivity in heroin-dependent individuals. However, whether the changes in cue-induced brain response were related to relapse was unknown. In a prospective study, we recruited 49 heroin-dependent patients under methadone maintenance treatment, a gold standard treatment (average daily dose 41.8 ± 16.0 mg), and 20 healthy subjects to perform the heroin cue-reactivity task during fMRI. The patients' subjective craving was evaluated. They participated in a follow-up assessment for 3 months, during which heroin use was assessed and relapse was confirmed by self-reported relapse or urine toxicology. Differences between relapsers and non-relapsers were analyzed with respect to the results from heroin-cue responses. Compared with healthy subjects, relapsers and non-relapsers commonly demonstrated significantly increased brain responses during the processing of heroin cues in the mesolimbic system, prefrontal regions and visuospatial-attention regions. However, compared with non-relapsers, relapsers demonstrated significantly greater cue-induced craving and the brain response mainly in the bilateral nucleus accumbens/subcallosal cortex and cerebellum. Although the cue-induced heroin craving was low in absolute measures, the change in craving positively correlated with the activation of the nucleus accumbens/subcallosal cortex among the patients. These findings suggest that in treatment-seeking heroin-dependent individuals, greater cue-induced craving and greater specific regional activations might be related to reward/craving and memory retrieval processes. These responses may predict relapse and represent important targets for the development of new treatment for heroin addiction.

Impaired self-awareness in human addiction: deficient attribution of personal relevance

Compromised self-awareness of illness-related deficits and behaviors in psychopathology (e.g., schizophrenia) has been associated with deficient functioning of cortical midline regions including the ventromedial prefrontal cortex (vmPFC), implicated in personal relevance. Here, we review and critically analyze recent evidence to suggest that vmPFC abnormalities could similarly underlie deficient tagging of personal relevance in drug addiction, evidenced by a constellation of behaviors encompassing drug-biased attention, negative outcome insensitivity, self-report/behavior dissociation, and social inappropriateness. This novel framework might clarify, for example, why drug-addicted individuals often ruin long-standing relationships or forego important job opportunities while continuing to engage in uncontrolled drug-taking. Therapeutic interventions targeting personal relevance and associated vmPFC functioning could enhance self-awareness and facilitate more adaptive behavior in this chronically relapsing psychopathology.

Cannabis abstinence during treatment and one-year follow-up: relationship to neural activity in men

Cannabis is among the most frequently abused substances in the United States. Cognitive control is a contributory factor in the maintenance of substance-use disorders and may relate to treatment response. Therefore, we assessed whether cognitive-control-related neural activity before treatment differs between treatment-seeking cannabis-dependent and healthy individuals and relates to cannabis-abstinence measures during treatment and 1-year follow-up. Cannabis-dependent males (N=20) completed a functional magnetic resonance imaging (fMRI) cognitive-control (Stroop) task before a 12-week randomized controlled trial of cognitive-behavioral therapy and/or contingency management. A healthy-comparison group (N=20) also completed the fMRI task. Cannabis use was assessed by urine toxicology and self-report during treatment, and by self-report across a 1-year follow-up period (N=18). The cannabis-dependent group displayed diminished Stroop-related neural activity relative to the healthy-comparison group in multiple regions, including those strongly implicated in cognitive-control and addiction-related processes (eg, dorsolateral prefrontal cortex and ventral striatum). The groups did not differ significantly in response times (cannabis-dependent, N=12; healthy-comparison, N=14). Within the cannabis-dependent group, greater Stroop-related activity in regions including the dorsal anterior cingulate cortex was associated with less cannabis use during treatment. Greater activity in regions including the ventral striatum was associated with less cannabis use during 1-year posttreatment follow-up. These data suggest that lower cognitive-control-related neural activity in classic 'control' regions (eg, dorsolateral prefrontal cortex and dorsal anterior cingulate) and classic 'salience/reward/learning' regions (eg, ventral striatum) differentiates cannabis-dependent individuals from healthy individuals and relates to less abstinence within-treatment and during long-term follow-up. Clinically, results suggest that treatment development efforts that focus on enhancing cognitive control in addition to abstinence may improve treatment outcomes in cannabis dependence.

Abstinence duration modulates striatal functioning during monetary reward processing in cocaine patients

Pre-clinical and clinical studies in cocaine addiction highlight alterations in the striatal dopaminergic reward system that subserve maintenance of cocaine use. Using an instrumental conditioning paradigm with monetary reinforcement, we studied striatal functional alterations in long-term abstinent cocaine-dependent patients and striatal functioning as a function of abstinence and treatment duration. Eighteen patients and 20 controls underwent functional magnetic resonance imaging during a Monetary Incentive Delay task. Region of interest analyses based on masks of the dorsal and ventral striatum were conducted to test between-group differences and the functional effects in the cocaine group of time (in months) with no more than two lapses from the first time patients visited the clinical service to seek treatment at the scanning time (duration of treatment), and the functional effects of the number of months with no lapses or relapses at the scanning session time (length of abstinence). We applied a voxel-wise and a cluster-wise FWE-corrected level (pFWE) at a threshold of P < 0.05. The patient group showed lower activation in the right caudate during reward anticipation than the control group. The regression analyses in the patients group revealed a positive correlation between duration of treatment and brain activity in the left caudate during reward anticipation. Likewise, length of abstinence negatively correlated with brain activity in the bilateral nucleus accumbens during monetary outcome processing. In conclusion, caudate and nucleus accumbens show a different brain response pattern to non-drug rewards during cocaine addiction, which can be modulated by treatment success.

Biomarkers for the development of new medications for cocaine dependence

There has been significant progress in personalized drug development. In large part, this has taken place in the oncology field and been due to the ability of researchers/clinicians to discover and develop novel drug development tools (DDTs), such as biomarkers. In cancer treatment research, biomarkers have permitted a more accurate pathophysiological characterization of an individual patient, and have enabled practitioners to target mechanistically the right drug, to the right patient, at the right time. Similar to cancer, patients with substance use disorders (SUDs) present clinically with heterogeneous symptomatology and respond variably to therapeutic interventions. If comparable biomarkers could be identified and developed for SUDs, significant diagnostic and therapeutic advances could be made. In this review, we highlight current opportunities and difficulties pertaining to the identification and development of biomarkers for SUDs. We focus on cocaine dependence as an example. Putative diagnostic, pharmacodynamic (PD), and predictive biomarkers for cocaine dependence are discussed across a range of methodological approaches. A possible cocaine-dependent clinical outcome assessment (COA)--another type of defined DDT--is also discussed. At present, biomarkers for cocaine dependence are in their infancy. Much additional research will be needed to identify, validate, and qualify these putative tools prior to their potential use for medications development and/or application to clinical practice. However, with a large unmet medical need and an estimated market size of several hundred million dollars per year, if developed, biomarkers for cocaine dependence will hold tremendous value to both industry and public health.

Common and distinct neural targets of treatment: changing brain function in substance addiction

Neuroimaging offers an opportunity to examine the neurobiological effects of therapeutic interventions for human drug addiction. Using activation likelihood estimation, the aim of the current meta-analysis was to quantitatively summarize functional neuroimaging studies of pharmacological and cognitive-based interventions for drug addiction, with an emphasis on their common and distinct neural targets. More exploratory analyses also contrasted subgroups of studies based on specific study and sample characteristics. The ventral striatum, a region implicated in reward, motivation, and craving, and the inferior frontal gyrus and orbitofrontal cortex, regions involved in inhibitory control and goal-directed behavior, were identified as common targets of pharmacological and cognitive-based interventions; these regions were observed when the analysis was limited to only studies that used established or efficacious interventions, and across imaging paradigms and types of addictions. Consistent with theoretical models, cognitive-based interventions were additionally more likely to activate the anterior cingulate cortex, middle frontal gyrus, and precuneus, implicated in self-referential processing, cognitive control, and attention. These results suggest that therapeutic interventions for addiction may target the brain structures that are altered across addictions and identify potential neurobiological mechanisms by which the tandem use of pharmacological and cognitive-based interventions may yield synergistic or complementary effects. These findings could inform the selection of novel functional targets in future treatment development for this difficult-to-treat disorder.

Choice to view cocaine images predicts concurrent and prospective drug use in cocaine addiction

BACKGROUND

Identifying variables that predict drug use in treatment-seeking drug addicted individuals is a crucial research and therapeutic goal. This study tested the hypothesis that choice to view cocaine images is associated with concurrent and prospective drug use in cocaine addiction.

METHODS

To establish choice-concurrent drug use associations, 71 cocaine addicted subjects (43 current users and 28 treatment seekers) provided data on (A) choice to view cocaine images and affectively pleasant, unpleasant, and neutral images [collected under explicit contingencies (when choice was made between two fully visible side-by-side images) and under more probabilistic contingencies (when choice was made between pictures hidden under flipped-over cards)]; and (B) past-month cocaine and other drug use. To establish choice-prospective drug use associations, 20 of these treatment-seeking subjects were followed over the next 6 months.

RESULTS

Baseline cocaine-related picture choice as measured by both tasks positively correlated with subjects' concurrent cocaine and other drug use as driven by the actively-using subjects. In a subsequent multiple regression analysis, choice to view cocaine images as compared with affectively pleasant images (under probabilistic contingencies) was the only predictor that continued to be significantly associated with drug use. Importantly, this same baseline cocaine>pleasant probabilistic choice also predicted the number of days drugs were used (cocaine, alcohol, and marijuana) over the next 6 months.

CONCLUSIONS

Simulated cocaine choice - especially when probabilistic and when compared with other positive reinforcers - may provide a valid laboratory marker of current and future drug use in cocaine addiction.

Individual differences in anterior cingulate activation associated with attentional bias predict cocaine use after treatment

Drug-dependent patients often relapse into drug use after treatment. Behavioral studies show that enhanced attentional bias to drug cues is a precursor of relapse. The present functional magnetic resonance imaging (fMRI) study examined whether brain regions involved in attentional bias are predictive of cocaine use after treatment. Attentional bias-related brain activity was measured-with a cocaine Stroop task-in cocaine-dependent patients during their first week in detoxification treatment and was used to predict cocaine use at 3-month follow-up. The predictive value of attentional bias-related brain activity in a priori defined regions of interest, in addition to other measures such as self-reports of substance severity, craving, and behavioral attentional bias were examined. The results show that craving in the week before treatment and individual variability in attentional bias-related activity in the dorsal anterior cingulate cortex (dACC) were significant predictors of days of cocaine use at 3-month follow-up and accounted for 45% in explained variance. Brain activity in the dACC uniquely contributed 22% of explained variance to the prediction model. These findings suggest that hyperactive attentional bias-related brain activity in the dACC might be a biomarker of relapse vulnerability as early as in the first week of detoxification treatment. Ultimately, this may help to develop individually tailored treatment interventions to reduce relapse risk.

Unbalanced neuronal circuits in addiction

Through sequential waves of drug-induced neurochemical stimulation, addiction co-opts the brain's neuronal circuits that mediate reward, motivation to behavioral inflexibility and a severe disruption of self-control and compulsive drug intake. Brain imaging technologies have allowed neuroscientists to map out the neural landscape of addiction in the human brain and to understand how drugs modify it.

Psychophysiological prediction of choice: relevance to insight and drug addiction

An important goal of addiction research and treatment is to predict behavioural responses to drug-related stimuli. This goal is especially important for patients with impaired insight, which can interfere with therapeutic interventions and potentially invalidate self-report questionnaires. This research tested (i) whether event-related potentials, specifically the late positive potential, predict choice to view cocaine images in cocaine addiction; and (ii) whether such behaviour prediction differs by insight (operationalized in this study as self-awareness of image choice). Fifty-nine cocaine abusers and 32 healthy controls provided data for the following laboratory components that were completed in a fixed-sequence (to establish prediction): (i) event-related potential recordings while passively viewing pleasant, unpleasant, neutral and cocaine images, during which early (400-1000 ms) and late (1000-2000 ms) window late positive potentials were collected; (ii) self-reported arousal ratings for each picture; and (iii) two previously validated tasks: one to assess choice for viewing these same images, and the other to group cocaine abusers by insight. Results showed that pleasant-related late positive potentials and arousal ratings predicted pleasant choice (the choice to view pleasant pictures) in all subjects, validating the method. In the cocaine abusers, the predictive ability of the late positive potentials and arousal ratings depended on insight. Cocaine-related late positive potentials better predicted cocaine image choice in cocaine abusers with impaired insight. Another emotion-relevant event-related potential component (the early posterior negativity) did not show these results, indicating specificity of the late positive potential. In contrast, arousal ratings better predicted respective cocaine image choice (and actual cocaine use severity) in cocaine abusers with intact insight. Taken together, the late positive potential could serve as a biomarker to help predict drug-related choice--and possibly associated behaviours (e.g. drug seeking in natural settings, relapse after treatment)--when insight (and self-report) is compromised.