Cognitive Function as a Transdiagnostic Treatment Target in Stimulant Use Disorders

ABSTRACT

Stimulant use disorder is an important public health problem, with an estimated 2.1 million current users in the United States alone. No pharmacological treatments are approved by the U.S. Food and Drug Administration for stimulant use disorder and behavioral treatments have variable efficacy and limited availability. Most individuals with stimulant use disorder have other comorbidities, most with overlapping symptoms and cognitive impairments. The goal of this article is to present a rationale for cognition as a treatment target in stimulant use disorder and to outline potential treatment approaches. Rates of lifetime comorbid psychiatric disorders among people with stimulant use disorders are estimated at 65% to 73%, with the most common being mood disorders (13% to 64%) and anxiety disorders (21% to 50%), as well as non–substance-induced psychotic disorders (<10%). There are several models of addictive behavior, but the dual process model particularly highlights the relevance of cognitive impairments and biases to the development and maintenance of addiction. This model explains addictive behavior as a balance between automatic processes and executive control, which in turn are related to individual (genetics, comorbid disorders, psychosocial factors) and other (craving, triggers, drug use) factors. Certain cognitive impairments, such as attentional bias and approach bias, are most relevant to automatic processes, while sustained attention, response inhibition, and working memory are primarily related to executive control. These cognitive impairments and biases are also common in disorders frequently comorbid with stimulant use disorder and predict poor treatment retention and clinical outcomes. As such, they may serve as feasible transdiagnostic treatment targets. There are promising pharmacological, cognitive, and behavioral approaches that aim to enhance cognitive function. Pharmacotherapies target cognitive impairments associated with executive control and include cholinesterase inhibitors (e.g., galantamine, rivastigmine) and monoamine transporter inhibitors (e.g., modafinil, methylphenidate). Cognitive behavioral therapy and cognitive rehabilitation also enhance executive control, while cognitive bias modification targets impairments associated with automatic processes. Cognitive enhancement to improve treatment outcomes is a novel and promising strategy, but its clinical value for the treatment of stimulant use disorder, with or without other psychiatric comorbidities, remains to be determined in future studies.

Keywords:

• Attentional retraining
• cocaine
• cognitive behavioral therapy
• cognitive bias modification
• cognitive enhancement
• cognitive remediation
• methamphetamine
• pharmacotherapy
• psychotherapy

Disclosures

Dr. Sofuoglu served as an expert witness on behalf of Pfizer in lawsuits related to varenicline. Dr. Carroll is a member of CBT4CBT LLC, which makes CBT4CBT, a computer-based version of cognitive behavioral therapy, available to qualified clinical providers and organizations on a commercial basis. She works with Yale University to manage any potential conflicts of interest. Dr. DeVito reports no financial relationships with commercial interests.

Funding

This research was supported by the Veterans Administration Mental Illness Research, Education and Clinical Center (MIRECC) and a grant from the National Institutes of Health (NIH) (P50 DA0924).