Cognitive Biases in Cannabis, Opioid, and Stimulant Disorders: A Systematic Review

Investigating brain dynamics and their association with cognitive control in opioid use disorder using naturalistic and drug cue paradigms

Objectives

Opioid use disorder (OUD) impacts millions of people worldwide. The prevalence and debilitating effects of OUD present a pressing need to understand its neural mechanisms to provide more targeted interventions. Prior studies have linked altered functioning in large-scale brain networks with clinical symptoms and outcomes in OUD. However, these investigations often do not consider how brain responses change over time. Time-varying brain network engagement can convey clinically relevant information not captured by static brain measures.

Methods

We investigated brain dynamic alterations in individuals with OUD by applying a new multivariate computational framework to movie-watching (i.e., naturalistic; N=76) and task-based (N=70) fMRI. We further probed the associations between cognitive control and brain dynamics during a separate drug cue paradigm in individuals with OUD.

Results

Compared to healthy controls (N=97), individuals with OUD showed decreased variability in the engagement of recurring brain states during movie-watching. We also found that worse cognitive control was linked to decreased variability during the rest period when no opioid-related stimuli were present.

Conclusions

These findings suggest that individuals with OUD may experience greater difficulty in effectively engaging brain networks in response to evolving internal or external demands. Such inflexibility may contribute to aberrant response inhibition and biased attention toward opioid-related stimuli, two hallmark characteristics of OUD. By incorporating temporal information, the current study introduces novel information about how brain dynamics are altered in individuals with OUD and their behavioral implications.

Intersection between social inequality and emotion regulation on emerging adult cannabis use

Emerging adulthood (EA; ages 18-25) is characterized by socioemotional and neurodevelopmental challenges. Cannabis is a widely used substance among EAs, and hazardous use may increase risk for sustained use patterns and related health consequences. Research shows differential increases in hazardous use by objective as well as subjective measures of social inequality, with more concerning trajectories for youth with greater experiences of social inequality. Learning how to flexibly monitor and modify emotions in proactive ways (i.e., emotion regulation) is a central developmental task navigated during the EA window. Challenges to and with emotion regulation processes can contribute to the emergence of mental health symptoms during EA, including hazardous cannabis use. In this perspective, we highlight emotion dysregulation and social inequality as two critical factors that interact to either buffer against or exacerbate cannabis use during the EA period, noting critical gaps in the literature that merit additional research. We recommend novel methods and longitudinal designs to help clarify how dynamic cognition-emotion interplay predicts trajectories of negative emotional experiences and cannabis use in EA.

Cognitive Biases and Addictive Disorders: A Bibliometric Review

Introduction: Since the early 2000s, there have been extensive investigations into cognitive biases in addictive disorders. The advances in the field have led to the discovery that cognitive bias exists in substance disorders and could in turn be modified. To date, there have been primary studies and meta-analysis demonstrating the existence of these biases and the effectiveness of cognitive bias modification (i.e., whereby such biases are retrained). There remains a lack of understanding of how the field has progressed and the research gaps, in light of the evidences provided by these primary studies. Objectives: A bibliometric analysis of the publications to date was performed to provide a map of the work that has been done so far. This would help researchers to better understand the development of cognitive bias research, the direction of the research, and the recent trends. Methods: For the purposes of this bibliometric research, Web of Science (WOS) was used in the identification of relevant articles. To identify the relevant articles, the following search strategy was implemented, that of ((((((TS = (“cognitive bias”)) OR TS = (“attention bias”)) OR TS = (“approach bias”)) OR TS = (“avoidance bias)) OR TS = (“interpretative bias”))). Bibliometric data analysis was conducted based on the identified articles. Results: A total of 161 citations were eventually included. These citations were published between 1994 and 2022. The average number of citations per documents was 26.73. Of these 161 citations, 122 were articles, 2 were editorials, 3 were corrections to the original manuscript, 5 were reviews, and 29 were meeting abstracts. The analysis of the trend of topics has shown that researchers were focused on understanding and gaining insights into cognitive biases and potentially examining the association between cognitive biases and cravings and aggression in the early days. Over the years, there has been an evolution into examining specific unconscious biases, namely, that of attention and approach biases. In the most recent years, the investigations have been more focused on examining bias modification/retraining. Conclusions: From our knowledge, this is the first bibliometric analysis that has been undertaken to explore all the publications related to cognitive bias in the field of addiction. The insights gained from this article could inform future research.

Protocol for the methamphetamine approach-avoidance training (MAAT) trial, a randomised controlled trial of personalised approach bias modification for methamphetamine use disorder

Background

Globally, methamphetamine use has increased in prevalence in recent years. In Australia, there has been a dramatic increase in numbers of people seeking treatment, including residential rehabilitation, for methamphetamine use disorder (MUD). While residential rehabilitation is more effective for MUD than withdrawal treatment (i.e. “detoxification”) alone, relapse rates remain high, with approximately half of rehabilitation clients using methamphetamine within 3 months of rehabilitation. “Approach bias modification” (ABM) is a computerised cognitive training approach that aims to dampen automatically triggered impulses to approach drugs and drug-related stimuli. ABM has been demonstrated to reduce alcohol relapse rates, but no randomised controlled trials of ABM for MUD have yet been conducted. We aim to test whether a novel “personalised” form of ABM, delivered during rehabilitation, reduces post-treatment methamphetamine use, relative to a sham-training control condition. Secondary outcomes will include dependence symptoms, cravings, and approach bias.

Methods

We aim to recruit 100 participants attending residential rehabilitation for MUD at 3 sites in the Melbourne metropolitan area. Participants will complete baseline measures of methamphetamine use, craving, dependence severity, and approach bias before being randomised to receiving 6 sessions of ABM or “sham” training. In the active condition, ABM will be personalised for each participant, using those methamphetamine images that they rate as most relevant to their recent methods of methamphetamine use as “avoidance” images and using positive images representing their goals or healthy sources of pleasure as “approach” images. Approach bias and craving will be re-assessed following completion of training, and methamphetamine use, dependence, and craving will be assessed 4 weeks and 3 months following discharge from residential treatment.

Discussion

This study is the first randomised controlled trial of ABM for MUD and also the first ABM study to test using a personalised set of both approach and avoid images for ABM training. If effective, the low cost and easy implementation of ABM means it could be widely implemented as a standard part of MUD treatment.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12620000072910. Registered on 30 January 2020 (prospectively registered): https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378804&isReview=true

Profiles of patients with cocaine and alcohol use disorder based on cognitive domains and their relationship with relapse

BACKGROUND

Relapse in drug use constitutes a research topic on addiction that is relevant for understanding both the addictive process and its clinical implications. The objective of this study was to explore if it is possible to identify patient profiles according to their performance on cognitive tasks whilst examining the relationship between such profiles and relapse.

METHODS

The sample consisted of 222 patients with dependence on cocaine and / or alcohol, of which 86 % were men. Cognitive domains related to salience, decision- making, and emotional processing were measured.

RESULTS

Latent class analysis revealed three patient profiles that differ in terms of performance on cognitive tasks. Two of these profiles are clearly differentiated in terms of their execution of the impulsive decision-making task. The third patient profile, unlike the latter two, is composed of patients with severe alterations in the three domains evaluated. Analysis revealed that patients in Profile 3 are those with the highest rates of relapse in cocaine (Profile 1 = 40.3 %; Profile 2 = 35.6 %; Profile 3 = 69.2 %; Chi2 = 9.169; p < .05) and cocaine and alcohol use (Profile 1 = 55.1 %; Profile 2 = 54.1 %; Profile 3 = 80 %; Chi2 = 6.698; p < .05).

CONCLUSIONS

The results support the postulates of the I-RISA model. From a clinical perspective, these findings highlight the need for a comprehensive evaluation of the cognitive domains involved in addiction.

A Literature Review of Attentional Biases amongst Individuals with Substance Dependency: Individual Differences and Modulating Factors

Introduction: Advances in experimental psychology have led to a better understanding of automatic, unconscious processes, referred to as attentional biases. Despite the growing evidence from meta-analytical studies, we still do not understand why some individuals have a greater magnitude of these biases, and why others have none. There has been little focus on elucidating individual differences and task parameters that affect the overall magnitude of the biases. In this opinion piece, we will attempt to identify these. We will then discuss both the research and clinical implications. Methods and Analysis: To identify the factors that modulated the magnitude of attentional biases across all the substance disorders (i.e., opioid use, cannabis use, and stimulant-use disorders), we performed a search using the bibliographic databases PubMed and MEDLINE. The search terminologies “attention bias” or “cognitive bias” or “approach bias” or “avoidance bias” were used when we looked for relevant articles. Results: It was evident from the published literature that several individual differences and factors modulated the magnitude of baseline biases. Across opioid, cannabis, and stimulant-use disorders, the most common individual differences identified were the severity of the dependence and the quantity of substance used. For both opioid and cannabis disorders the timing of stimulus presentation influenced the detection of attentional bias; it appeared that short stimulus timing was better able to detect attentional bias. Other identified individual differences included subjective craving and impulsiveness. The results highlight several research and clinical implications. Conclusions: The discovery of these individual differences and factors of the task paradigm that affect the magnitude of attentional biases will help in the future conceptualization of attention-bias-modification intervention.

Cognitive Bias Modification for Addictive Disorders: Emerging Knowledge and Persistent Gaps

The advances in experimental psychology have led to the discovery of unconscious, automatic biases (attentional and approach biases) that account for the lapse and relapses amongst individuals with addictive disorders. To date, there has been extensive investigation into the assessment and modification of attention biases amongst individuals with the highly prevalent substance use disorders. Alternative modalities, such as technology, has also been evaluated for the delivery of these interventions. Given this, the specific objectives of this perspective article are in highlighting the emerging knowledge that has accrued over the last three years, and in addressing several of the research gaps in the previous article. Firstly, this perspective article will examine the evidence for biases and bias modification amongst the highly prevalent substance use disorders. This article will also examine how such bias modification has been utilized clinically. Secondly, this perspective article will also examine how technology has been applied to these bias modification interventions. Thirdly, this article will also examine the literature to highlight the biological underpinnings following bias modification. Fourthly, this article also examines the limitations of existing bias modification paradigms and methods taken to better these conventional interventions. The article concludes with highlighting the outstanding gaps in the current knowledge. To date, there remains mixed evidence for the modification of attention biases; and there are a paucity of studies examining the effectiveness of mobile delivery of bias intervention. Only one study has considered patients’ perspective in the development of an intervention. There remained several gaps in the knowledge, which future research could address.

The short-term and long-term effects of cannabis on cognition: recent advances in the field

The aim of this review is to discuss the most recent evidence for the short-term and long-term effects of cannabis on cognition. The evidence that cannabis intoxication is associated with short-term impairment across several basal cognitive domains, including learning and (episodic) memory, attentional control, and motor inhibition is increasing. However, evidence regarding the effects of long-term heavy cannabis use on cognition remains equivocal. Cannabis research suffers from difficulties in measuring cannabis exposure history, poor control over potential subacute effects, and heterogeneity in cognitive measures and sample composition. Multidisciplinary collaborations and investment in studies that help overcome these difficulties should be prioritized.

Mobile Assessment of Acute Effects of Marijuana on Cognitive Functioning in Young Adults: Observational Study

Background

Mobile assessment of the effects of acute marijuana on cognitive functioning in the natural environment would provide an ecologically valid measure of the impacts of marijuana use on daily functioning.

Objective

This study aimed to examine the association of reported acute subjective marijuana high (rated 0-10) with performance on 3 mobile cognitive tasks measuring visuospatial working memory (Flowers task), attentional bias to marijuana-related cues (marijuana Stroop), and information processing and psychomotor speed (digit symbol substitution task [DSST]). The effect of distraction as a moderator of the association between the rating of subjective marijuana high and task performance (ie, reaction time and number of correct responses) was explored.

Methods

Young adults (aged 18-25 years; 37/60, 62% female) who reported marijuana use at least twice per week were recruited through advertisements and a participant registry in Pittsburgh, Pennsylvania. Phone surveys and mobile cognitive tasks were delivered 3 times per day and were self-initiated when starting marijuana use. Completion of phone surveys triggered the delivery of cognitive tasks. Participants completed up to 30 days of daily data collection. Multilevel models examined associations between ratings of subjective marijuana high (rated 0-10) and performance on each cognitive task (reaction time and number of correct responses) and tested the number of distractions (rated 0-4) during the mobile task session as a moderator of the association between ratings of subjective marijuana high and task performance.

Results

Participants provided 2703 data points, representing 451 reports (451/2703, 16.7%) of marijuana use. Consistent with slight impairing effects of acute marijuana use, an increase in the average rating of subjective marijuana high was associated with slower average reaction time on all 3 tasks—Flowers (B=2.29; SE 0.86; P=.008), marijuana Stroop (B=2.74; SE 1.09; P=.01), and DSST (B=3.08; SE 1.41; P=.03)—and with fewer correct responses for Flowers (B=−0.03; SE 0.01; P=.01) and DSST (B=−0.18; SE 0.07; P=.01), but not marijuana Stroop (P=.45). Results for distraction as a moderator were statistically significant only for certain cognitive tasks and outcomes. Specifically, as hypothesized, a person’s average number of reported distractions moderated the association of the average rating of subjective marijuana high (over and above a session’s rating) with the reaction time for marijuana Stroop (B=−52.93; SE 19.38; P=.006) and DSST (B=−109.72; SE 42.50; P=.01) and the number of correct responses for marijuana Stroop (B=−0.22; SE 0.10; P=.02) and DSST (B=4.62; SE 1.81; P=.01).

Conclusions

Young adults’ performance on mobile cognitive tasks in the natural environment was associated with ratings of acute subjective marijuana high, consistent with slight decreases in cognitive functioning. Monitoring cognitive functioning in real time in the natural environment holds promise for providing immediate feedback to guide personal decision making.

Heavy cannabis use, dependence and the brain: a clinical perspective

AIMS

To summarize and evaluate our knowledge of the relationship between heavy cannabis use, cannabis use disorder (CUD) and the brain.

METHODS

Narrative review of relevant literature identified through existing systematic reviews, meta-analyses and a PubMed search. Epidemiology, clinical representations, potential causal mechanisms, assessments, treatment and prognosis are discussed.

RESULTS

Although causality is unclear, heavy and dependent cannabis use is consistently associated with a high prevalence of comorbid psychiatric disorders and learning and memory impairments that seem to recover after a period of abstinence. Evidence regarding other cognitive domains and neurological consequences, including cerebrovascular events, is limited and inconsistent. Abstinence after treatment is only achieved in a minority of cases; treatment targeted at reduction in use appears have some success. Potential moderators of the impact of CUD on the brain include age of onset, heaviness of use, CUD severity, the ratio of ∆9-tetrahydrocannabinol to cannabidiol and severity of comorbid disorders.

CONCLUSIONS

Current evidence of long-term effects of daily cannabis use and cannabis use disorder on brain-related outcomes is suggestive rather than conclusive, but use is associated with psychiatric morbidity and with cognitive impairments that recover after a period of abstinence.

Variations in the Visual Probe Paradigms for Attention Bias Modification for Substance Use Disorders

Advances in experimental psychology have provided evidence for the presence of attentional and approach biases in individuals with substance use disorders. Traditionally, reaction time tasks, such as the Stroop or the Visual Probe Task, are commonly used in the assessment of attention biases. The Visual Probe Task has been criticized for its poor reliability, and other research has highlighted that variations remain in the paradigms adopted. However, a gap remains in the published literature, as there have not been any prior studies that have reviewed stimulus timings for different substance use disorders. Such a review is pertinent, as the nature of the task might affect its effectiveness. The aim of this paper was in comparing the different methods used in the Visual Probe Task, by focusing on tasks that have been used for the most highly prevalent substance disorders—that of opiate use, cannabis use and stimulant use disorders. A total of eight published articles were identified for opioid use disorders, three for cannabis use disorders and four for stimulant use disorders. As evident from the synthesis, there is great variability in the paradigm adopted, with most articles including only information about the nature of the stimulus, the number of trials, the timings for the fixation cross and the timings for the stimulus set. Future research examining attentional biases among individuals with substance use disorders should take into consideration the paradigms that are commonly used and evaluate the optimal stimulus and stimulus-onset asynchrony timings.

Feasibility and acceptability of approach bias modification during methamphetamine withdrawal and related methamphetamine use outcomes

Approach bias modification (ApBM), a computerised cognitive training task which aims to reduce automatic, impulsive responding to drug-related cues, has been found to reduce alcohol consumption among individuals seeking treatment for their drinking. However, this approach has not been trialled in patients with methamphetamine use disorder (MUD), where altered impulsivity and reward processing are well-established. As such, this study aimed to examine the feasibility and acceptability of four consecutive days of ApBM training during a residential admission for methamphetamine withdrawal. Abstinence rates were examined 2-weeks and 3-months post-discharge. In terms of uptake, 52 of the 99 eligible patients approached agreed to participate and 47 of these 52 commenced training. Uptake and training completion rates (62%) were lower than those achieved in similar trials of ApBM for residential alcohol withdrawal, suggesting there are challenges to its delivery in this setting. This is likely due to the severity of acute methamphetamine withdrawal syndrome and associated behavioural characteristics. However, participants' ratings of the task and reports of post-session craving suggest acceptability was high. Abstinence rates were 61% at 2 weeks and 54% at 3-months, which compare favourably with the abstinence rates observed in a previous large treatment outcome study. The evidence of acceptability and apparent effectiveness suggest future trials of ApBM with MUD patients are warranted. However, ApBM may be more feasible in certain settings or among particular sub-groups where patients are more clinically stable and therefore more likely to complete the training (e.g., residential rehabilitation, after acute withdrawal has subsided).

Altered Activity of SK Channel Underpins Morphine Withdrawal Relevant Psychiatric Deficiency in Infralimbic to Accumbens Shell Pathway

Drug addiction can be viewed as a chronic psychiatric disorder that is related to dysfunction of neural circuits, including reward deficits, stress surfeits, craving changes, and compromised executive function. The nucleus accumbens (NAc) plays a crucial role in regulating craving and relapse, while the medial prefrontal cortex (mPFC) represents a higher cortex projecting into the NAc that is active in the management of executive function. In this study, we investigated the role of the small conductance calcium-activated potassium channels (SK channels) in NAc and mPFC after morphine withdrawal. Action potential (AP) firing of neurons in the NAc shell was enhanced via the downregulations of the SK channels after morphine withdrawal. Furthermore, the expression of SK2 and SK3 subunits in the NAc was significantly reduced after 3 weeks of morphine withdrawal, but was not altered in the dorsal striatum. In mPFC, the SK channel subunits were differentially expressed. To be specific, the expression of SK3 was upregulated, while the expression of SK2 was unchanged. Furthermore, the AP firing in layer 5 pyramidal neurons of the infralimbic (IL) cortex was decreased via the upregulations of the SK channel-related tail current after 3 weeks of morphine withdrawal. These results suggest that the SK channel plays a specific role in reward circuits following morphine exposure and a period of drug withdrawal, making it a potential target for the prevention of relapse.