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Article Excerpt
ALCOHOL CRAVING HAS BEEN CONSIDERED one of the core components of alcoholism and a strong predictor of subsequent relapse since the 1950s (Bottlender and Soyka, 2004; de Bruijn et al., 2004; Flannery et al., 2003; Jellinek, 1955; Ludwig and Wikler, 1974; Roberts et al., 1999). In the last decade, research has focused on improving our understanding of alcohol craving by developing new instruments to measure this phenomenon. Compared with the previous single-item questionnaires that are mostly unvalidated and unable to provide internal consistency (Drobes and Thomas, 1999; Tiffany et al., 2000), new multi-item craving instruments have demonstrated high reliability and validity (Anton et al., 1996; Flannery et al., 1999). These instruments include the Alcohol Urge Questionnaire (AUQ; Bohn et al., 1995), the Obsessive Compulsive Drinking Scale (OCDS; Anton et al., 1995, 1996), and the Penn Alcohol Craving Scale (PACS; Flannery et al., 1999).
Although new craving scales are available, few studies have investigated the prevalence of craving among alcohol-dependent patients or the clinical correlates of alcohol craving. In one study assessing treatment response to naltrexone (Revia) in alcohol-dependent subjects, Monterosso and colleagues (2001) reported that 25% of study participants had low craving, 42% had moderate craving, and 33% had high alcohol craving based on the PACS. Because these subjects were recruited from a clinical trial with multiple inclusion/exclusion criteria, however, the results may not generalize to the larger population of alcohol-dependent individuals. In a study of outpatients with alcohol-use disorders, Westerberg (2000) demonstrated that 67% of patients had low alcohol craving. However, the Westerberg study used a single-item analog craving scale that may have less predictive validity (Bohn et al., 1995). Despite their limitations, these two studies indicate that 25%-67% of alcoholics may have no craving or mild craving depending on study sample or method of craving assessment.
This considerable variability in the levels of alcohol craving suggests that stratifying alcohol-dependent subjects based on craving may have important clinical implications, because extent of craving may be associated with clinical course, prognosis, and even some choices among available treatments. Craving alcoholics differ from noncraving alcoholics in several ways. In laboratory and field settings, Litt et al. (2000) demonstrated that craving alcoholics had severe alcohol dependence and greater mood disturbance (especially anger and anxiety). In laboratory settings, negative mood and alcohol cues increased alcohol craving (Cooney et al., 1997; Rubonis et al., 1994). Two investigative groups noted that stress played an important role in alcohol craving and relapse (Breese et al., 2005; Sinha, 2001). Malcolm et al. (2000) showed that alcohol craving and previous multiple detoxifications were correlated. Alcohol withdrawal symptoms increased alcohol craving, perhaps as a homeostatic mechanism to alleviate physical symptoms (Ludwig et al., 1974; Roelofs, 1985). Two studies reported that better treatment response to the anticraving agent naltrexone occurred in association with higher alcohol craving (Jaffe et al., 1996; Monterosso et al., 2001). In sum, alcohol craving has been related to several dimensions of alcoholism severity and associated psychopathology.
Studies conducted to date have not determined the rate of craving, levels of craving, and clinical correlates of craving in a clinical setting by using reliable multi-item instruments. The purpose of this study was to do the following: (1) determine the rate of alcohol craving among alcohol-dependent outpatients; and (2) ascertain alcoholism severity and comorbid psychopathology in alcohol-dependent patients classified into three craving groups (low, moderate, high). We hypothesized the following: (1) that not all alcoholics would have craving; and (2) that higher alcohol craving would be directly proportional to severe alcoholism, worse withdrawal, and greater psychopathology.
Method
Subjects
Outpatient veterans (N = 101) with alcohol dependence were recruited from the addiction outpatient clinic at the Minneapolis Veterans Affairs Medical Center between November 2004 and March 2005. Potential subjects were referred by outpatient clinical staff. All subjects were currently enrolled in the outpatient addiction clinic before participation. The typical patient was scheduled to visit the addiction clinic every 1-3 months, although current visit interval ranged from 1 day to 6 months for case management or medication management. Some patients attend this clinic even after several years of sobriety for relapse prevention or treatments of comorbid psychiatric disorders.
Inclusion criteria included the following: (1) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), lifetime alcohol dependence determined by the Structured Clinical Interview for DSM-IV (First et al., 1995); and (2) the ability to understand the study procedures and the informed consent. The only exclusion criterion was current use of medications that may affect alcohol craving (e.g., naltrexone, topiramate [Topamax]; about 5% of total screening sample). We included lifetime alcohol-dependent patients regardless of current sobriety to investigate the relationship between the current craving and clinical course of alcohol dependence in an outpatient setting. Co-occurring substance-use disorders or other Axis I disorders were not a basis for study exclusion.
The study was reviewed and approved by the Institutional Review Board of the Minneapolis Veterans Affairs Medical Center. Written informed consent was obtained from all subjects.
Measures
Alcohol craving was assessed with the PACS (Flannery et al., 1999). The PACS is a 5-item self-rated scale designed to assess the alcohol craving severity (frequency, intensity, duration, resistance, and overall craving) during the preceding 1 week. Each item has a score range of to 6 (maximum total craving score = 30). The PACS has demonstrated excellent reliability and good construct/discriminant/predictive validity (Flannery et al., 1999). The PACS was chosen as the primary measure of craving, because it is a multi-item, single-factor scale and assesses only alcohol craving (Flannery et al., 1999). Additionally, alcohol craving was also measured by the OCDS (Anton et al.,...
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