Competing neurobehavioral decision systems theory of cocaine addiction: From mechanisms to therapeutic opportunities

Abstract

Cocaine dependence is a difficult-to-treat, chronically relapsing disorder. Multiple scientific disciplines provide distinct perspectives on this disorder; however, connections between disciplines are rare. The competing neurobehavioral decision systems (CNDS) theory posits that choice results from the interaction between two decision systems (impulsive and executive) and that regulatory imbalance between systems can induce pathology, including addiction. Using this view, we integrate a diverse set of observations on cocaine dependence, including bias for immediacy, neural activity and structure, developmental time course, behavioral comorbidities, and the relationship between cocaine dependence and socioeconomic status. From the CNDS perspective, we discuss established and emerging behavioral, pharmacological, and neurological treatments and identify possible targets for future treatments. The ability of the CNDS theory to integrate diverse findings highlights its utility for understanding cocaine dependence and supports that dysregulation between the decision systems contributes to addiction.

Keywords: Cocaine dependence; Competing neurobehavioral decision systems; Delay discounting; Dual systems; Executive function; Impulsivity; Self-control; Transcranial magnetic stimulation.

Figure 1

The relative control of the impulsive and executive decision systems, represented graphically. The diagonal line represents regulatory balance between the systems. The shaded regions indicate an imbalance between the two systems producing a bias for immediate over delayed rewards.

Figure 2

Percentage of cocaine use in the past month, by age group. The results from the 2003 and 2013 National Survey on Drug Use and Health Surveys are presented. Percentage of use increases with age, which then slowly dissipates over time.