If addiction is not a chronic brain disease, how can it be fixed? Since the majority of addicted people are able to get unhooked without professional assistance, how do they do it? They stop consuming the substance or engaging in the behavior, to the degree that it becomes a controllable problem, possibly not a problem at all. Addiction may damage the brain, but at least some of the damage can be repaired, and most addicted people will come to see it as a phase and not the story of their lives.

The brain of the addict is damaged in very specific ways, according to Dr. Reinout W. Wiers, author of A New Approach to Addiction and Choice. Some of the ways the functioning of the brain is impaired by addiction include:

• Attention Bias — the tendency to be alert to reward signals
• Approach Bias — the tendency to be attracted to signs of reward
• Anxiety — an attentional bias toward threats
• Delay Discounting — sensitivity to the immediacy of reward
• Impaired Working Memory — related to impulse control and delay discounting

Not only are these functions damaged in heavy drinkers and others with substance use disorders, but if they are not repaired, recovery often fails. “When someone is addicted,” writes Dr. Wiers, “it is crucial for sustained recovery that these functions recover.” 

I’ll spare you the details of the many studies that have found ways to improve these cognitive functions, but have failed to show any improvement in addiction recovery efforts. The science that looks at whether these functions can be improved in a way that supports sustained recovery is small but substantial. 

Some of the methods covered in Chapter 8 of A New Approach to Addiction and Choice include:

Episodic Future Thinking. Strengthening the ability to imagine oneself in the future and to chart a path toward achieving that vision. It’s a popular subject here at AddictionNews.

Goal Management Training. Studies show that it is beneficial to patients recovering from multiple substance addictions and that the benefits last. It works best when patients set their own goals and there is steady feedback, “which is motivating for the confidence in recovery,” writes Dr. Wiers.

Contingency Management. Rewarding behavior by paying for positive test results. When financial rewards are combined with group training, a remarkable 41% of smokers were able to stop smoking for one year. It is also considered the most effective treatment for opioid addiction.

Good Behavior Games. Rewarding impulse control with games that are entertaining and have a social element leads to strengthening working memory, impulse control and self-control.

Community Reinforcement. Addiction recovery has a better chance of succeeding when it involves the environment as well as the person. Treatment that considers a patient’s needs for housing, medical care, employment, and social services has a better chance of success because it reinforces episodic future thinking.

Mindfulness Training. Wiers admits he “initially viewed mindfulness somewhat skeptically,” but has been won over by clinical trials that demonstrate it “work[s] about as well as other proven effective therapies, such as cognitive behavioral therapy.” Like goal management, mindfulness transcends addiction recovery to often become a lifelong practice once learned, “which is not typically the case with other [cognitive repair] methods,” notes Dr. Wiers.

The majority of the chapter is devoted to Dr. Wiers’ decades-long efforts to improve cognitive biases. The way you measure attentional bias, approach bias, working memory, and impulse control is usually by displaying imagery and seeing what people react to most quickly. Dr. Wiers used essentially the same methods to train the brains of volunteers and patients away from making bad choices.

The experiments first involved using a joystick to either pull an image toward you or push it away. Then the images were put into either profile or landscape frames, and subjects were asked to push or pull on different frames and ignore the picture itself. 

With experimentation, Dr. Wiers finds that it helps to push images to be avoided, such as alcohol cues, and pull images to be substituted, such as other beverages or activities. The amazing thing is it works! It slows down patients’ “Type 1” automatic responses to cues (attention bias, attraction bias) and gets them to pause and consider another course of action. Thus, impulse control.

The experiments have since been replicated many times, with an impressive 8% to 13% less relapse a year after the end of treatment. The results have been confirmed by fMRI brain scans. It’s a fairly simple treatment: six daily sessions, 20 minutes per day, pushing images of booze away. It has become standard treatment in Germany which requires, unlike most countries, that addiction studies funds be followed up on a year after treatment ends.

There are many caveats. The cognitive training is added to standard CBT and does not work as a substitute or on its own. CBT improves goal management and episodic future thinking, while cognitive training strengthens risk avoidance and impulse control. Furthermore, cognitive training does not work delivered over the Internet:

Internet studies showed no effects across the board; the bias often did not change, nor did anxiety decrease more in the group that had received training compared to the group that had received placebo training.

Artificial intelligence and avatars are changing some of the thinking on that. For now, the impact of cognitive training is no greater than a placebo unless the training is part of a treatment program focused on abstinence. Dr. Wiers does not report on any studies with opioid addiction, only alcohol and smoking.

The way the training works for alcoholics undergoing the standard treatment is somewhat remarkable. Cognitive training — pushing away images of alcohol — helps break the automatic reaction to cues. Patients who have the treatment recover faster and are graduated from treatment faster. They relapse later than those who receive the standard CBT treatment and also those who receive the placebo cognitive training. It works best for the people who are the heaviest drinkers. The effect is “stronger for alcohol-addicted patients who diagnosed with comorbid anxiety or depression,” writes Dr. Wiers.

Dr. Wiers has refined his model of cognitive training in conjunction with Dr. Catalina Kopetz at Wayne State University, into ABC Training. ABC stands for…

• Antecedents — the context that elicits the desire to use
• Behavioral alternatives — individually chosen substitute behaviors
• Consequences of behavioral choice — benefits and drawbacks of different choices

ABC Training brings conditional training closer to cognitive behavioral therapy. The images pushed away must be consistent, the images pulled close must be meaningful to the patient, the long-term benefits or costs of choice must be brought into short-term focus. Dr. Wiers writes, “It’s important [for patients] to think of good alternatives for the situation beforehand,” something we call substitution and have covered at length on AddictionNews.

Can we add up all of what we know about how addiction works and how addiction treatment works, and devise a therapy that is both inexpensive and effective? We will give that a try in the coming edition of AddictionNews.

Written by Steve O’Keefe. First published September 18, 2024.

Sources:

A New Approach to Addiction and Choice: Akrasia and the Nature of Free Will, by Reinout W. Wiers, to be published by Routledge in 2025.

Image Copyright: fabrikacrimea.