Commentary on Gowin et al. (2014): Brain is behavior—methamphetamine
dependence and recovery
Why do people use methamphetamine? There are many
answers to this question. Often the answers help to define
membership in subgroups likely to use the drug, includ-
ing women, youth, gay men, gangs, sex workers and
people who live in rural areas ; but why do people
continue to use methamphetamine once they become
addicted? As defined in diagnostic manuals, metham-
caused by the negative consequences to general health,
work/school activities, social/family relationships and
involvement of law enforcement from using metham-
phetamine. Despite severity, such consequences (i.e.
losses) are not sufficient to invoke or sustain cessation
among those with dependence. Even for clinicians, it can
seem mystifying that the addicted individual in recovery
has such problems with the decision-making task that
presents itself daily, often multiple times per day, i.e. to
choose low-value and often distal outcomes (not use
high-reinforcing value of the drug—and additional
response costs (losses) from that choice.
The paper by Gowin et al.  provides neuroimaging
involves repeatedly making choices between potential
correspond with moderate losses, methamphetamine-
dependent individuals showed reduced activation in the
bilateral rostral anterior cingulate cortex and increased
the highest risks, reduced activity in the rostral anterior
cingulate gyrus was observed among individuals with
as to why individuals with methamphetamine depend-
ence continue to use the drug despite knowledge of
negative consequences: their losses do not mean a great
deal. For individuals with methamphetamine depend-
ence, potential losses from methamphetamine use can be
discounted as irrelevant or even as manageable, which
may provide a partial biological explanation as to why
it is so hard for individuals engaged in treatment not
to use methamphetamine.
Of course, the decision-making task used in this study
is narrow and limited, but the outcomes offer a strong
heuristic that seems apt for individuals trying to establish
sustained abstinence from methamphetamine depend-
ence. This is so much the case that the authors end their
paper with a provocative challenge: ‘treatment providers
should take this deficiency [of a neurobiological basis for
individuals not being able to appreciate losses from con-
tinued methamphetamine use] into consideration’.
While a laudable translational ‘ahoy’ from those in the
pies for methamphetamine dependence have modest
effect sizes that will probably not be improved appreciably
by recognizing such deficits with clients. Indeed, while
the evidence is somewhat mixed , impairments in
learning, memory and information processing speed are
observed in methamphetamine-dependent individuals
; each of these is needed precisely to be able to use
talk therapies, such as cognitive–behavioral therapy and
and to successfully instill and sustain abstinence from
One therapy, however, that may directly address the
neurobiological substrate of
inhibition among individuals with methamphetamine
dependence is contingency management. Contingency
ing value in exchange for scheduled and successive
biomarkers that document abstinence from methamphe-
tamine. In theory, the therapy pits the perceived value of
tangible rewards against the value of the drug. Efficacy
data show sustained effects to one year, with equal or
superior outcomes to cognitive–behavioral therapies [5,6],
and an effect size of 0.6 [7,8]. If this treatment were a
medication, it would be widely marketed and acknowl-
edged as the standard of care for stimulant dependence.
challenge issued by the authors intended to produce
the strength of rewards so they might compete more
effectively with the reinforcing value of methampheta-
mine. One obvious option is pharmacological. Dopamine
salience of contingencies in randomized controlled trials
of cocaine-dependent individuals . Another option
may involve manipulating the way in which rewards
are delivered. In controlled secondary data analyses,
frequently spending rewards earned in a contingency
management schedule (compared to saving for a high-
value good) significantly increased the likelihood that
methamphetamine-dependent individuals would appear
at their next clinic visit abstinent from drug .
impairment in impulse
© 2014 Society for the Study of Addiction
Addiction, 109, 248–249
It is exciting that basic neuroscientists are thinking
about experiments that help to define the neurobiological
factors that support methamphetamine dependence.
While the term ‘translational science’ is used in many
scientific venues, this basic neuroimaging study has
clear value to most clinicians. Although findings offer
fascinating directions for future neuroimaging studies,
efforts such as this should help to motivate clinicians
towards the development (and implementation) of
optimally efficacious treatments for methamphetamine
dependence, both pharmacological and behavioral, that
target decision-making about immediate gain in the face
of longer-term losses.
Declaration of interests
phetamine abstinence, neuroimaging, recovery.
Department of Family Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA 90095-7087, USA.
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© 2014 Society for the Study of Addiction
Addiction, 109, 248–249