Efficacy of Pharmacological Interventions in Targeting Decision-Making Impairments across Substance and Behavioral Addictions

Decision-making impairments reflect tendencies towards risky or unwise choices as manifested by presence of psychiatric symptoms or cognitive impairment (e.g. representation of value, inhibitory control-response selection, learning). Such impairments are suggested by the hallmark symptoms of substance and behavioral addictions, which include escalation over time (of substance intake or a given behavior), lack of control, neglect of other domains of life, and cognitive distortions (such as ‘chasing losses’ in gambling disorder). Amongst the putative behavioral addictions, most epidemiological data exist for gambling disorder, which is now included in DSM-5 as a substance-related and addictive disorder. However, other disorders share parallels and may also constitute behavioral addictions, such as compulsive stealing (kleptomania), compulsive shopping, and compulsive sexual behavior. The current paper presents a narrative review of evidence for cognitive decision-making impairments in addictions, as well as pharmacological treatments of these disorders that may have relevance for improving decision-making. We find that objective decision-making deficits have been widely reported in patients with substance use disorders and gambling disorder, compared to controls. Decision-making in the other behavioral addictions is under-studied. Evidence-based pharmacological treatments for some of these addictive disorders, for example, opioid antagonists and glutamatergic agents, modulate neural systems playing key roles in decision-making. But clinical trials have seldom examined effects of such treatments on objective decision-making measures. Future research directions are discussed, including the need to include standardized outcome measures of decision-making (tasks and imaging) alongside traditional clinical measures, to better understand and enhance underlying treatment mechanisms.