The following databases were searched: MEDLINE (via PubMed); Biomedical Research (EMBASE); the Latin-American and Caribbean Health Sciences Literature database (BIREME); and the Psychological Abstracts databases (PsycINFO). Articles published by the end of January 2020 were eligible. The search queries were Alcohol OR cocaine, OR heroin, marijuana, OR inhalants, OR tobacco, OR substance use, OR substance addiction, OR drug dependence AND Anger. This extensive electronic database search was supplemented by a search of theses and dissertations, abstracts, expert consultations, and a review of relevant documents to identify any additional studies in the field, in an attempt to minimize publication bias. Ada Johansson, the author of one included study, was contacted and responded with additional information about anger scores that were not reported in the manuscript.1414. Johansson A, Santtila P, Corander J, Jern P, Von der Pahlen B, Varjonen M, et al. Controlling anger in self-reported sober and alcohol intoxicated states: moderating effects of trait anger and alcohol consumption. Scand J Psychol. 2011;52:382-8.
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Anger and anxiety can be experienced as symptoms of craving, as part of the desire to obtain the pleasurable sensation associated with PSU.5757. Legrand AC, Price M. Emotionally valenced stimuli impact response inhibition in those with substance use disorder and co-occurring anxiety and depression symptoms. J Affect Disord. 2020;266:639-45. Anger can also be understood as a result of long-term changes in the brain that result in the emergence of a negative emotional state, or withdrawal symptoms. Abrupt discontinuation of long-term illicit opioid and crack-cocaine use can produce withdrawal symptoms as early as hours after the most recent use. Initial symptoms of anxiety, agitation, and restlessness are distressing to patients, which may lead to increased irritability and aggression.5858. Neale J, Kalk NJ, Parkin S, Brown C, Brandt L, Campbell AN, et al. Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: exploratory mixed methods analysis. J Subst Abuse Treat. 2020;117:108099. Abstinence in alcohol users after treatment is different, as there is no evidence of urgency of use as is seen with substances such as heroin and crack-cocaine. This can be related to several factors, but those most described in the literature are emotional aspects linked to negative affects that trigger a craving for alcohol use.5959. Stohs ME, Schneekloth TD, Geske JR, Biernacka JM, Karpyak VM. Alcohol craving predicts relapse after residential addiction treatment. Alcohol Alcohol. 2019;54:167-72. These neuroadaptive modifications involve dynamic readjustments toward a new set point. This causes an imbalance in the reward system and failure to experience pleasure with natural stimuli, reinforcing and increasing the likelihood of reacting to negative emotional cues with anger, anxiety, and depression.4343. Ruisoto P, Contador I. The role of stress in drug addiction. An integrative review. Physiol Behav. 2019;202:62-8.,4545. Carreiro S, Chintha KK, Shrestha S, Chapman B, Smelson D, Indic P. Wearable sensor-based detection of stress and craving in patients during treatment for substance use disorder: a mixed methods pilot study. Drug Alcohol Depend. 2020;209:107929.
In psychiatric disorders such as anxiety and depression, the tendency is for symptoms to decrease with treatment and prolonged abstinence from PSU.6363. Volkow ND, Koob GF, McLellan AT. Neurobiological advances from the brain disease model of addiction. N Engl J Med. 2016;374:363-71. However, surprisingly, there was no difference in anger scores in different contexts and abstinence times: patients undergoing treatment for 14 to 28 days without using psychoactive substances (alcohol, cocaine, and heroin dependence); incarcerated patients intoxicated with alcohol; intoxicated individuals drawn from the general community in Finland; patients on a university campus with 1 day of abstinence from khat; patients in therapeutic communities with 60 to 95 days of abstinence from alcohol, tobacco, cocaine, crack, and multiple substances; and university undergraduate students intoxicated with alcohol. The hypothesis is that symptoms may actually worsen in the first 1-2 days due to lack of the psychoactive substance, increasing craving, reactivity to negative effects, and stress, and, consequently, increasing anger, which can increase the likelihood of relapse and interfere with prognosis.6464. Venkataraman A, Turton S, Lingford-Hughes A. Drug use and associated neuropsychiatric conditions. United Kingdom: Oxford Textbook of Neuropsychiatry: Oxford University Press; 2020. In patients with 14 to 95 days of abstinence, anger can be a serious and lasting problem, with a link between personality traits and daily episodes of anger.6565. Volkow ND, Koob G. Brain disease model of addiction: why is it so controversial? Lancet Psychiatry. 2015;2:677-9. 2ff7e9595c
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