Medications and Alcohol Craving

Alcohol Research & Health, Fall, 1999 by Robert M. Swift

The use of medications as an adjunct to alcoholism treatment is based on the premise that craving and other manifestations of alcoholism are mediated by neurobiological mechanisms. Three of the four medications approved in the United States or Europe for treating alcoholism are reported to reduce craving; these include naltrexone ([ReVia.sup.TM]), acamprosate, and tiapride. The remaining medication, disulfiram (Antabuse(r)), may also possess some anticraving activity. Additional medications that have been investigated include ritanserin, which has not been shown to decrease craving or drinking levels in humans, and ondansetron, which shows promise for treating early onset alcoholics, who generally respond poorly to psychosocial treatment alone. Use of anticraving medications in combination (e.g., naltrexone plus acamprosate) may enhance their effectiveness. Future studies should address such issues as optimal dosing regimens and the development of strategies to enhance patient compliance. KEY WORDS: AOD (alco hol and other drug) craving; anti alcohol craving agents; alcohol withdrawal agents; drug therapy; neurobiological theory; alcohol cue; disulfiram; naltrexone; calcium acetylhomotaurinate; dopamine; serotonin uptake inhibitors; buspirone; treatment outcome; reinforcement; neurotransmitters; patient assessment; literature review

criteria for defining alcoholism vary widely. Most definitions of alcohol dependence include the following descriptors: a compulsion to seek and consume alcohol, a loss of control over consumption after beginning a drinking session, and a strong likelihood of relapse during or after withdrawal. [1] These manifestations may be accompanied by a conscious desire or urge to consume alcohol (i.e., craving). Craving can occur spontaneously, or it can be elicited by internal or external stimuli, known as cues (see sidebar by Tiffany on p. 216). Internal cues may include emotional states (e.g., anxiety) or symptoms of acute alcohol withdrawal. External cues may include exposure to alcohol-related environments or objects (e.g., bottles of alcoholic beverages or advertisements).

Results of craving research are often difficult to interpret, because the subjective nature of craving makes it difficult to assess and quantify. Also, the quality and intensity of craving may vary according to personal characteristics as well as environmental circumstances or experimental conditions. Nevertheless, phenomena associated with craving may have important implications for preventing and treating alcoholism. For example, high levels of craving are associated with increased probability of relapse, particularly during the early stages of the posttreatment period (Anton et al. 1996). In addition, treatments that reduce craving have been shown to reduce subsequent alcohol use (Monti et al. 1993). [2]

In the past decade there has been increasing interest in the use of medications (i.e., pharmacotherapy) to improve the effectiveness of psychosocial alcoholism treatment (Litten et al. 1996; Swift 1999). Alcoholism pharmacotherapy is based on the premise that alcohol use is mediated through specific neurobiological and behavioral mechanisms that initiate and maintain drinking. Several medications have demonstrated their ability to reduce alcohol consumption in humans, and several of these drugs are reported to reduce alcohol craving. Researchers can reasonably conclude that medications which reduce craving may be effective in alcoholism treatment.

ASSESSING AND MEASURING CRAVING

Because craving is a subjective phenomenon, researchers commonly assess its intensity based on the self-reports of study participants. [3] The simplest craving assessments are single-item questionnaires. In the most basic approach, the subject responds to a question (such as, "How much do you desire alcohol right now?") by selecting one of three to five statements that indicate increasing levels of intensity (e.g., from "not at all" to "very much"). In some studies the patient rates his or her craving on a visual analog scale (VAS). In this approach, the patient places a mark on a line that is approximately 4 inches long and divided into arbitrary units beginning with zero. The reliability of single-item craving assessments is variable.

Multi-item questionnaires include the Obsessive Compulsive Drinking Scale (Anton et al. 1995), which contains 14 questions, each rated on a scale from 0 to 4, and the Alcohol Urge Questionnaire, which contains 8 statements rated from 1 to 7 (Bohn et al. 1995).

Craving is sometimes assessed by measuring certain physiological changes thought to accompany craving, such as changes in heart rate, blood pressure, salivation, and sweat gland activity. Finally, craving can be assessed by directly observing a subject's drinking behavior. Behavioral measurements may include number of drinks consumed, time elapsed between cue exposure and initiation of drinking (i.e., latency), and time elapsed between commencement and completion of drinking.