Miller-The ASAM Principles of Addiction Medicine, 7e

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SECTION 1 • Basic Science and Core Concepts

executive functioning ability which may exacerbate the effects of addiction. In addition to the changes in brain function ob served through human neuroimaging studies, there are well-established alterations in brain structure in multiple pop ulations of individuals who use substances, which may have important clinical relevance to treatment. Individuals who use cocaine, for example, have lower gray matter volume in the medial prefrontal cortex than controls, 143,144 which appears to be proportional to their length of cocaine use. 145 Individuals seeking treatment are more likely to remain abstinent from cocaine after several months of residential treatment if they had higher levels of medial prefrontal cortex gray matter at treatment initiation. 146 Additionally, extended abstinence may lead to recovery in frontal cortical gray matter regions. 147 Re cent longitudinal work supports these findings, showing in creases in prefrontal gray matter volume over 6 months of abstinence. 148 The relationship between altered gray and white matter structure and length of use as well as recurrence of use rates has also been observed in people who compulsively use alcohol 149,150 and smoke tobacco. 151,152 MOVING FORWARD This chapter has focused on the alterations in brain structure and functional activity associated with initial drug reinforce ment and addiction. We have not, however, addressed the changes in brain structure and function that may adapt follow ing extended abstinence. While this is beyond the scope of the present chapter, there are many studies, which suggest that the limbic system is a critical biomarker for abstinence. 153-155 Ad ditionally, as we attempt to bridge the neurobiological findings from clinical and preclinical studies of chronic drug use to absti nence, it will also be important to integrate the literature on be havioral patterns that predict successful recovery. Through the integration of these components, we will be much more likely to generate individually tailored therapies, both pharmacological and behavioral, for those that find themselves on the continuum of addiction, from vulnerable adolescents to treatment-seeking individuals that recurrently return to previous use. ACKNOWLEDGEMENTS This chapter represents an update and revision of previous chapters in this series, most recently by Dr David Roberts from the last edition. We are indebted to Dr Roberts for his work and retain much of his prose in this current edition. REFERENCES 1. Zahm DS. The evolving theory of basal forebrain functional-anatomical ‘macrosystems.’ Neurosci Biobehav Rev. 2006;30(2):148 ‐ 172. 2. Gerfen CR. The neostriatal mosaic: Multiple levels of compartmental organization in the basal ganglia. Annu Rev Neurosci. 1992;15:285 ‐ 320. 3. Squire LR, Stark CE, Clark RE. The medial temporal lobe. Annu Rev Neurosci. 2004;27:279 ‐ 306.

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