Basics on CravingBasics on Craving

Steven D. LaRowe, Ph.D.Steven D. LaRowe, Ph.D.

Center for Drug and Alcohol ProgramCenter for Drug and Alcohol ProgramMedical University of South CarolinaMedical University of South Carolina

Substance Abuse Treatment CenterSubstance Abuse Treatment CenterRalph H. Johnson VAMCRalph H. Johnson VAMC

Craving: DefinitionCraving: Definition Merriam-Webster: “An intense, urgent, or Merriam-Webster: “An intense, urgent, or

abnormal desire or longing.”abnormal desire or longing.” My definition: Motivation to acquire somethingMy definition: Motivation to acquire something In recovery, some people are beset with very In recovery, some people are beset with very

strong cravings. However, a substantial portion strong cravings. However, a substantial portion of people do not experience the “intense desire of people do not experience the “intense desire or longing.”or longing.”

Goal in therapy is to recognize what triggers Goal in therapy is to recognize what triggers craving so that we can purposefully, and with craving so that we can purposefully, and with forethought, put things in place to manage forethought, put things in place to manage craving when and if it occurscraving when and if it occurs

But what if they experience no But what if they experience no craving?craving?

People have their own “working definitions” of People have their own “working definitions” of cravingcraving

I suspect they think of craving as “uncontrollable I suspect they think of craving as “uncontrollable urge.” urge.”

I suspect that addicts view craving as an either/or I suspect that addicts view craving as an either/or phenomenon. Either you have it, or you don’t.phenomenon. Either you have it, or you don’t.

I think of craving as part of a continuum of I think of craving as part of a continuum of motivation, with the “uncontrollable urge” being at motivation, with the “uncontrollable urge” being at the most intense end of the spectrumthe most intense end of the spectrum

(By the way, why WOULDN’T they (By the way, why WOULDN’T they have craving)have craving)

Some don’t ever reportSome don’t ever reportSome are motivated to be “better”Some are motivated to be “better”Some are in treatment and not in their Some are in treatment and not in their

usual environment, so not encountering usual environment, so not encountering the same triggersthe same triggers

Some have external inducements (i.e. Some have external inducements (i.e. housing that requires being clean, housing that requires being clean, probation, recent crisis) that affect probation, recent crisis) that affect motivational state motivational state

Another way to frame craving: Another way to frame craving: Wanting, “Thinking About it”Wanting, “Thinking About it”

Sometimes, after craving is Sometimes, after craving is denied, I will ask them if denied, I will ask them if they “want to use” the drug, they “want to use” the drug, or if they “think” about it – or if they “think” about it – sometimes they will say sometimes they will say yes, even if they deny yes, even if they deny cravingcraving

Treatment-seeking cocaine Treatment-seeking cocaine addicts report higher ratings addicts report higher ratings of “wanting to use” than of “wanting to use” than ratings of “craving” in ratings of “craving” in response to slides depicting response to slides depicting cocaine and cocaine use cocaine and cocaine use (Study by Malcolm et al. in (Study by Malcolm et al. in progress)progress)

6

7

8

9

10

11

Crave Want to Use

N = 78, F(1,77) = 6.2, p < .05

Continuum of CravingContinuum of CravingMotivation

0

25

50

75

100

No Craving Craving

Reminder

Pleasant Memory

Planning how one might get some

Engaging in behaviors to get some

Craving doesn’t lastCraving doesn’t last

I need to look of an “official reference” but estimates I need to look of an “official reference” but estimates range between 5 to 15 minutes, give or take, range between 5 to 15 minutes, give or take, depending on the source. depending on the source.

Craving Ratings

0

1

2

3

4

5

6

7

1:30p 2:00p 2:05p 2:15p 2:30p 3:00p

Cra

vin

g L

evel

•MUSC Study (Brady et. Al), n = 30 cocaine addicts.•Cues presented for 20 minutes. Cues consisted of videos and paraphernalia.•Significant changes in Craving over time, F(5,145) = 14.9, p < .001.•All time points greater than baseline, except for 3pm.

StartCues

EndCues

Cues activate the BrainCues activate the BrainStudy at MUSC, Myrick et al. 2004. Participants looked at slides, got a “taste” of alcohol.

“GO” Circuits active in alcoholics

(“STOP” Circuits active too!)

Cues can activate the brain, and Cues can activate the brain, and you might not even realize it!!!!you might not even realize it!!!!

Childress et al. 2008Childress et al. 2008 Show slides depicting Show slides depicting

neutral, aversive, neutral, aversive, sexual content, as sexual content, as well as cocainewell as cocaine

Show slides 33msec Show slides 33msec (fast as an eyeblink)(fast as an eyeblink)

Scan brain using fMRIScan brain using fMRI

Activation by “Unseen” slidesActivation by “Unseen” slides

More response to subliminal cocaine slides = greater More response to subliminal cocaine slides = greater positive response later to supraliminal presentations of positive response later to supraliminal presentations of those slidesthose slides

CONCLUSION: Your motivational circuits can be CONCLUSION: Your motivational circuits can be activated without you even knowing about it! activated without you even knowing about it!

Unseen (subliminal) Unseen (subliminal) cocaine slides cocaine slides activated striatum (aka activated striatum (aka “go” circuits)“go” circuits)

What does all this mean?What does all this mean? An addict’s brain is activated by cues, including An addict’s brain is activated by cues, including

their basic motivational circuitrytheir basic motivational circuitry You don’t have to be aware of seeing the cues You don’t have to be aware of seeing the cues

to have them activate your brainto have them activate your brain From this, I conclude that motivational From this, I conclude that motivational

processes can get started long before we realize processes can get started long before we realize itit

In therapy, it is our job to help patients uncover In therapy, it is our job to help patients uncover what gets their motivational circuits goingwhat gets their motivational circuits going

They need to monitor cravings to help them They need to monitor cravings to help them discover these subtle cues and to prepare a plan discover these subtle cues and to prepare a plan to help neutralize these cuesto help neutralize these cues

Brain CircuitsBrain Circuits

Cue information is refined through cortical processing and available for conscious recognition

Cue is consciously recognized. Decision to acquire or not is determined by pre-existing goals/rules

Cue is NOT consciously recognized. Decision to acquire is determined by sense of urgency.

Cue information fades and is NOT refined by cortical processing

Unrefined cue information registered in limbic areaPreparations made to act (acquire)

Although very quickly presented, unrefined cue information STILL registered in limbic areaPreparations made to act (acquire)

..And what if they aren’t craving?..And what if they aren’t craving?

Let’s assume Let’s assume thoughts and thoughts and memories are memories are “precursors” to “precursors” to cravingcraving

Monitor where those Monitor where those occur – this gives us occur – this gives us our best guess where our best guess where cravings might occurcravings might occur

Those are easier to Those are easier to overcome anywayovercome anyway

Motivation

0

25

50

75

100

No Craving Craving

Reminder

Pleasant Memory

Planning

Engaging in behaviors

What do we do?What do we do?

First, teach clients to monitor cravings and First, teach clients to monitor cravings and “pre-cravings”“pre-cravings”

Explain that cravings are elicited by Explain that cravings are elicited by ExternalExternal triggers in our surrounding triggers in our surrounding environment (e.g. people, places, things)environment (e.g. people, places, things)

Explain that cravings are elicited by Explain that cravings are elicited by InternalInternal triggers (e.g. emotions, both triggers (e.g. emotions, both positive and negative)positive and negative)

What do we do, page 2What do we do, page 2 We need to find out what/when these triggers We need to find out what/when these triggers

occuroccur Once we discover this, we put a plan in placeOnce we discover this, we put a plan in place For external:For external:

Avoid (plan to avoid those things)Avoid (plan to avoid those things) Distract (keep busy, avoid too much idle time and Distract (keep busy, avoid too much idle time and

boredom)boredom) Escape (have a way to get away)Escape (have a way to get away) Endure (cravings don’t last, ride it out)Endure (cravings don’t last, ride it out)

For internal: various emotion management For internal: various emotion management strategies – can’t avoid them, suppression is strategies – can’t avoid them, suppression is preservation.preservation.

What to do, part 3What to do, part 3 You’ve explained the rationale, now collect the data!You’ve explained the rationale, now collect the data! Give handout for craving monitoringGive handout for craving monitoring You can use the 0-100 scale to rate cravings. You can use the 0-100 scale to rate cravings.

0-25 = “just a thought”0-25 = “just a thought” 25-50 = “A pleasant memory, reminisce”25-50 = “A pleasant memory, reminisce” 50-75 = “Wouldn’t it be nice, here’s how I could do it.”50-75 = “Wouldn’t it be nice, here’s how I could do it.” 75-100 = You start to act on the plan75-100 = You start to act on the plan

When the person has craving, have them record as When the person has craving, have them record as much detail about the situation as possible – this helps much detail about the situation as possible – this helps identify triggers that they might otherwise not have identify triggers that they might otherwise not have noticed noticed

Use this data to help devise specific plans to neutralize Use this data to help devise specific plans to neutralize these cues (for future sessions)these cues (for future sessions)

Other facts about cravingOther facts about craving

People tend to assume that in the future, People tend to assume that in the future, they will feel the same way they do nowthey will feel the same way they do now

This holds true for craving. People will This holds true for craving. People will make future predictions of craving based make future predictions of craving based on how much they are craving nowon how much they are craving now

This means if they are not craving now, This means if they are not craving now, they will underestimate the amount of later they will underestimate the amount of later craving they will experiencecraving they will experience

Rat never gets cokein training cage

Rat gets coke in training cage

Non-addicted rat relaxing in home cage

Addicted rat also relaxing in home cage

Non-addicted rat doesn’t press when returned

Addicted rat resumeswhen returned

People in treatment will not crave, because treatment is not their using environment.Craving can re-awaken when the recovering addict returns to that using environment.

Evidence for underprediction…Evidence for underprediction…

Article on the Empathy GapArticle on the Empathy GapDependent measure was “Willingness to Dependent measure was “Willingness to

Accept Craving” – asks people how Accept Craving” – asks people how much $ they’d need to be paid for them much $ they’d need to be paid for them to tolerate cravingto tolerate craving

High value = craving more strong, need High value = craving more strong, need to pay more $ for me to tolerate itto pay more $ for me to tolerate it

Low value = craving lower, you don’t Low value = craving lower, you don’t need to pay me so much to put up with itneed to pay me so much to put up with it

Underprediction evidenceUnderprediction evidence People either deprived People either deprived

(hot) or recently (hot) or recently smoked (cold). smoked (cold). Deprived people Deprived people needed more $ to needed more $ to accept cravingaccept craving

Predicted their Predicted their willingness to accept willingness to accept cravingcraving

Result: People who Result: People who just smoked assumed just smoked assumed they’d be more willing they’d be more willing to accept craving than to accept craving than they actually did laterthey actually did later

Prediction made at session 1

Actual rating made at session 2

Another issue with Craving: Cues Another issue with Craving: Cues can be more compelling over timecan be more compelling over time

““Incubation of craving”Incubation of craving”Train rats to push lever for cocaineTrain rats to push lever for cocainePair cue with cocainePair cue with cocaineStop cocaine infusions Stop cocaine infusions extinction extinctionShow cue later, rat presses again = Show cue later, rat presses again =

reinstatement reinstatement mode for relapse mode for relapseDepending on how long you wait, cues Depending on how long you wait, cues

can elicit more reinstatementcan elicit more reinstatement

Cues get stronger: evidenceCues get stronger: evidence

Modeling Addiction: Training Rats to Self Administer Cocaine

Lever Press = Coke + Light

\

If no coke, rat stops pressingIf no coke, rat stops pressing

ExtinctionLever Press = No Programmed Consequences

THE PRESSING STOPS – IT HAS EXTINGUISHED

But what happens when the light comes back? The pressing STARTS Again!

The Power of a CUE or The Power of a CUE or TRIGGER…TRIGGER…

The light is an animal version of a ‘cue’ or The light is an animal version of a ‘cue’ or ‘trigger’ that can cause the return of ‘trigger’ that can cause the return of craving/motivation to seek drugscraving/motivation to seek drugs

Generally, people would expect cues to Generally, people would expect cues to get weaker over time…get weaker over time…

Evidence for this goes against what one Evidence for this goes against what one might expect…might expect…

CUES can GET STRONGERCUES can GET STRONGER

But they reach a peak and But they reach a peak and weakenweaken

Caution: The drug itself can still Caution: The drug itself can still activate the behavior – doesn’t activate the behavior – doesn’t

seem to changeseem to change

What this means?What this means? People in treatment often assume that craving People in treatment often assume that craving

won’t return and underestimate the future impact won’t return and underestimate the future impact of craving.of craving.

The impact – a craving that takes you by The impact – a craving that takes you by surprise has more affect on behaviorsurprise has more affect on behavior

Cue induced craving may get stronger over time, Cue induced craving may get stronger over time, but can drop if given enough timebut can drop if given enough time

Why tell patients this? Because patients will Why tell patients this? Because patients will assume something’s wrong if craving resumesassume something’s wrong if craving resumes