# Unpredictable Drug Access and its Relevance for Substance Use Disorders: A Critical Review

## TL;DR

This paper reviews how unpredictable drug access may worsen substance use disorders and treatment outcomes, especially among those in poverty.

## Contribution

The paper introduces the novel perspective that unpredictable drug access increases drug misuse severity and relapse rates.

## Key findings

- Unpredictable drug access increases drug intake and choice in laboratory settings.
- It may lead to worse treatment outcomes and higher relapse rates in real-world scenarios.
- Preclinical findings suggest persistent drug-seeking behavior despite negative consequences.

## Abstract

Many factors contribute to drug use and the development of substance use disorders (SUDs). We and others have argued that individuals who misuse illicit drugs face circumstances in which their access to drugs is variable or unpredictable, particularly for those who are experiencing poverty. Herein, we make the case that such unpredictable drug access increases drug intake and choice, particularly when the time and effort required to obtain drugs is relatively large. If translated to real-world scenarios, unpredictable access could lead to increased severity of drug misuse, poorer treatment outcomes, persistence of drug seeking during periods of drug unavailability, drug taking despite negative consequences, and increased relapse rates, though additional research is surely needed. We describe how variable drug access can be evaluated in the laboratory, review prior research that has compared variable vs. fixed drug access, provide a summary of preclinical findings based on the literature reviewed, and end with implications for policy and treatment for individuals with SUDs.