Clinical and laboratory assessment of the subjective experience of drug craving

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Abstract

Measures of subjective drug craving — often defined as the experience of an intense or compelling urge or desire — may be used to predict relapse, evaluate psychological and pharmacological treatments, and test theories of addiction and craving. This review summarizes both direct self-report questionnaires and indirect behavioral, physiological and reaction time measures designed to assess craving for alcohol, amphetamines, cocaine, heroin, marijuana, and tobacco. Multi-item questionnaires have typically been based on one of four underlying conceptualizations of addiction or craving (obsessive–compulsive, approach-avoidance, multi-dimensional, intensity–frequency–duration). Most multi-item self-report questionnaires have high internal consistency, correlate significantly with single-item craving ratings, and demonstrate several aspects of construct validity. Proposed indirect or proxy measures of craving include drug dreams, speed of drug consumption, willingness to work for drug access, selection of monetary rewards over drug access, psychophysiological reactivity, and attentional bias to drug cues. These proxy measures of craving are presumed to obviate self-report biases, to be less subject to conscious self-control, and to reflect craving which the person may not be able to articulate; however, there have been too few demonstrations of their validity and they have too many practical limitations to supplant self-report measures of craving at this time.

Introduction

The term “craving” is used regularly by recreational smokers, drinkers and drug takers, those diagnosed as abusing or dependent on alcohol and drugs, and by laboratory researchers and clinicians. However, the best way to define and measure this construct remains the subject of considerable debate. For example, one key question is whether the definition and measurement of craving should comprise components across multiple response domains, including emotional experiences (e.g., desire, anxiety, irritation, excitement), cognitive experiences (e.g., intrusive thoughts, sensory images, drug dreams, anticipated outcomes of consumption), overt behavior (e.g., work to acquire a drug, rapid or excessive consumption, selecting drug consumption over other rewards), and psychophysiological experiences (e.g., perspiration, salivation, changes in respiration and blood pressure, activation of specific brain regions).

Substance abusers often report experiences in more than one of these response domains (Merikle, 1999), but the concept of “response de-synchrony” apparently applies to drug craving as it does to the assessment of other psychological experiences (Heiby & Haynes, 2004). That is, there is sometimes limited correspondence, within an individual, among the emotional, cognitive, behavioral and psychophysiological responses considered indicative of craving (e.g., Brandon et al., 1996, Drobes and Tiffany, 1997, Kassel and Shiffman, 1992, Ooteman et al., 2006, Tiffany and Conklin, 2000). This phenomenon may occur both because of individual differences in the experience of drug craving across response domains (just as people experience fear, depression, hunger and pain inconsistently across response domains), and because of limited reliability and validity of measures used to assess the experience of craving in each response domain.

Another question is whether craving should be defined as any urge or inclination to take a drug, or should be reserved to describe only a compelling or intense desire (Kozlowski et al., 1989, Sitharthan et al., 1992). Not everyone would agree with Halikas, Kuhn, Crosby, Carlson, and Crea (1991) who proposed the analogy that craving is to desire as panic is to anxiety — that is, an intense and intrusive sensation that disrupts concentration and performance creating not just discomfort, but outright distress. Many psychologists and drug takers would agree, however, that the urge, desire or intention to ingest a drug must exceed some threshold to be considered craving (Pickens & Johanson, 1992). That is, drug craving is more than simply choosing to take a drug, just as a food craving is defined as more than simply a food preference (Pelchat, 2002, Weingarten and Elston, 1990).

Assessment is also complicated because craving may be conceptualized and assessed as both a stable “background” inclination or propensity to seek drugs and as a relatively acute and short-lived experience of an urge (Ferguson & Shiffman, 2009). The intensity and experiential components of both types of craving may wax and wane, depending on such factors as mood (Maude-Griffin and Tiffany, 1996, Shiffman and Waters, 2004), perceived availability of the drug (MacKillop and Lisman, 2007, Wertz and Sayette, 2001), and blood levels of the drug (Greenwald, 2002). Whether one is seeking to measure relatively transient urges or a relatively stable preoccupation with or behavioral readiness to consume a drug has implications for the time period over which one measures the emotional, cognitive, behavioral and physiological experiences one considers indicative of craving and for how one evaluates the reliability and validity of a craving measure (Sayette, Shiffman, Tiffany, Niaura, Martin, & Shadel, 2000).

There is also disagreement about the role of craving in the definition of drug addiction (Hartman, Caskey, Olmstead, & Jarvik, 1998). Although the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV-TR; American Psychiatric Association, 2000) does not list the psychological experience of craving as a diagnostic criterion of substance abuse or substance dependence, the DSM-IV-TR does state that craving is “likely to be experienced by most (if not all) individuals with substance dependence” (p. 192). Advocating for the centrality of craving to drug addiction, some researchers have argued that the experience of craving (combined with withdrawal symptoms) better discriminates substance abuse from dependence than the current DSM-IV criteria (deBruijn, Korzec, Koerselman, & van den Brink, 2004).

Debate about the experiential components, threshold, temporal stability and diagnostic value of craving has not deterred investigators from proposing multiple methods to assess the psychological experience of drug craving. Reliable and valid measures of craving would have several advantages for both clinicians and researchers. One advantage is that craving might help predict readiness for discharge from treatment (Anton & Drobes, 1998) or increased likelihood of relapse following treatment (e.g., Doherty et al., 1995, Hartz et al., 2001, Killen and Fortmann, 1997, Robbins and Ehrman, 1998, Rohsenow and Monti, 1999, Tracy, 1994).

Evaluations of treatment interventions for substance abuse also would benefit from valid assessment of craving. For example, reduction of craving has been targeted as an outcome measure in the evaluation of psychotherapies such as cue exposure therapy (e.g., Conklin & Tiffany, 2002), and reviews of pharmacological therapies for drug dependence have suggested that specific “types” of craving (e.g., craving for relief of withdrawal symptoms versus craving for rewarding intoxication) may respond differentially to drug replacement/substitution medications such as methadone and “anti-craving” medications such as naltrexone and acamprosate (Addolorato et al., 2005, O'Brien, 2005). Researchers also depend on being able to manipulate and assess craving to test predictions based on psychological theories of addiction and craving (Addolorato et al., 2005, Drummond, 2001, Franken, 2003, Kavanagh et al., 2005, Tiffany, 1990, Verheul et al., 1999).

Recognizing these advantages, researchers have proposed a variety of both direct self-report questionnaires and indirect behavioral and physiological measures to assess the psychological experience of craving for illicit substances such as marijuana, heroin, amphetamines and cocaine, and for licit substances such as tobacco and alcoholic beverages. Several reviews have summarized examples of and challenges to devising measures of drug craving (e.g., Anton and Drobes, 1998, Mezinskis et al., 2001, Potgieter et al., 1999, Sayette et al., 2000), but no recent article has provided a comprehensive summary of the diverse procedures employed to assess subjective craving. Therefore, as a service to practicing clinicians and laboratory-based researchers, this article reviews the underlying rationales, practical advantages and disadvantages, and psychometric properties of direct and indirect measures of drug craving.

Section snippets

Single-item ratings of subjective craving

One commonly employed way of assessing craving is a single-item Likert-type rating or visual analogue scale (VAS). These scales are usually anchored by terms such as “none” or “not at all” and “extreme” or “strongest ever experienced,” and the respondent is instructed to circle a numeral or make a mark on a 100-mm line to indicate the degree of urge, craving, or desire for the target drug experienced at that moment (or over some specified period of hours or days). Investigators may provide a

Features of multi-item self-report questionnaires

The past 15 to 20 years have seen a notable increase in the development of multi-item self-report questionnaires of craving for both licit and illicit drugs. Table 1 provides a summary of 24 such instruments, with a listing of the source document (column 1), name of the questionnaire (column 2), target drug and underlying conceptualization of addiction or craving on which the instrument was based (column 3), characteristics of the sample on which the instrument was initially tested (column 4),

Free-response procedures

The subjective experience of craving may also be assessed without the use of printed items and fixed response options by using a free-response or think-aloud procedure (Haaga, 1989, Shadel et al., 2004). The instructions for this procedure are similar to the free association instruction in psychoanalytic therapy, in that participants are asked to speak their thoughts and feelings aloud without judging how appropriate they might seem, except that they do so during cue exposure or after imagining

Indirect or proxy measures of craving

The recent development and evaluation of indirect measures of drug addiction and craving has been driven by a combination of practical, empirical and theoretical considerations (de Houwer, 2006). In addition to the limitations of self-report questionnaires and concerns about the validity of introspection outlined above, some theories of addiction and craving (e.g., Berridge and Robinson, 1995, Franken, 2003, McCusker, 2001) propose that conditioned stimuli elicit automatic drug seeking and

Summary and conclusions

Developing and evaluating measures of subjective craving are complicated by questions regarding the emotional, cognitive, physiological and behavioral components of craving, the threshold separating preference from craving, the degree to which one is interested in an acute and fluctuating experience of craving or a relatively stable pre-occupation with or inclination to use a target drug, and the degree to which substance users are aware of and able to report on their motivational state of

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