Daily ratings measures of alcohol craving during an inpatient stay define subtypes of alcohol addiction that predict subsequent risk for resumption of drinking
Introduction
Both depressive symptoms and alcohol craving have been postulated as important predictors of relapse in patients with addictive disorders. Indeed, affective disorders are well known to be overrepresented in those with alcohol dependence and a major motivation for treatment seeking. While alcohol craving has been consistently recognized as an important construct in alcohol-dependent individuals, the relationship to alcohol consumption has not been clear in cross-sectional research (Ooteman et al., 2006, Wrase et al., 2006, Yoon et al., 2006). However, little prospective research and almost no research in older adults has been conducted to understand the implication of affect or craving on recovery.
While most of the epidemiological literature has focused on the association between affective disorders and addictive disorders, there is evidence that depressive symptoms not meeting criteria for a depressive disorder are also important as a cause of disability (Leibson et al., 1999, Lyness and King, 1999, Chopra et al., 2005). Moreover, there is some literature to suggest that affective disturbances may play a role in alcohol relapse and recovery particularly among older adults (Schonfeld and Dupree, 1991). Overall the interaction between depression or affective regulation and substance use is complex with some research findings suggesting a strong interaction between depression and substance use disorders and other studies showing weaker interactions. While the association between alcohol use and depression is difficult to ascertain, daily diary methods have increasingly been used as an effective methodology for better understanding causal relationships and how daily variations in mood relate to disability (Chepenik et al., 2006).
Alcohol craving is recognized as a possible endophenotype of addiction and has received substantial interest as a target for pharmacological interventions. Craving can be considered a trait phenomenon or enhanced or triggered by a variety of different cues including stress. At least one study has demonstrated that stress stressed induced craving has been associated with poor long-term outcomes in cocaine addicted individuals (Sinha et al., 2006). However, there are few studies examining the effects of alcohol craving on the impact of relapse. Studies of alcohol craving do suggest a strong relationship between alcohol craving, mood, and mu-OR binding in specific brain regions of recently abstinent, alcohol-dependent men (Bencherif et al., 2004). This result is interesting in that naltrexone, an opioid antagonist, has been demonstrated to reduce alcohol craving in clinical and laboratory studies (Palfai et al., 1999, Monterosso et al., 2001, Drobes et al., 2004).
Understanding changes in alcohol craving and affective symptoms following treatment entry is critical for developing risk profiles for relapse and developing personalized treatment alternatives. Indeed, understanding the trajectory of these constructs may allow greater diagnostic precision with a disorder that is extremely heterogeneous. The aim of this study was to describe the course of alcohol craving and affect (positive and negative) during the first month of recovery from alcohol dependence. We hypothesized that there would be subgroups of patients with high negative affect and high craving that would be associated with subsequent relapse, however, the study design did not prespecify the number of subgroups. The project took advantage of two treatment residential treatment programs where the use of alcohol and benzodiazepines is strictly prohibited during this time and thus reduces any confound from alcohol use during this critical period of recovery. In addition to studying the trajectories of each of these constructs, we sought to validate their importance by examining outcomes during the first 6 months of outpatient therapy. The study was conducted in middle aged and older adults to reduce confounds related to polysubstance dependence and because this cohort is under-represented in prior research.
Section snippets
Methods
Ninety-five alcohol-dependent subjects admitted to one of two residential treatment programs were enrolled in this study. Eligible subjects had to be at least 50 years of age and meet DSM-IV criteria for alcohol dependence. Subjects were not included if they had a current DSM-IV diagnosis of any psychoactive substance dependence other than alcohol, caffeine, cannabis, or nicotine. Subjects with psychosis or manic symptoms were not included. The study was reviewed and approved by the
Baseline characteristics
For the overall sample, the average age of the subjects was 61.6 years (S.D. = 7.7) (range = 50–81) with the majority being Caucasian (98%). Clinical characteristics prior to treatment suggest that subjects drank on an average of 81 (S.D. = 22) percent of days during the 90 days preceding enrollment, and drank heavily on an average of 53 (S.D. = 39) percent of these days. Subjects drank an average of 9.9 (S.D. = 8.5) drinks/day during this period. With regard to problem drinking, the average SIP score
Discussion
Results demonstrate three distinct groups of alcohol-dependent patients based on daily measures of alcohol craving, positive affect, and negative affect. In general, each class was associated with differential severity of symptoms. While there was an association between negative affect and alcohol craving, only alcohol craving was significantly related to maintaining abstinence. Interestingly, alcohol craving was not associated with quantity and frequency of drinking at the time of admission.
Role of funding source
Funding for this study was provided by a funding endowment to the Hazelden Foundation. The benefactors had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Authors Oslin, Blow, and Slaymaker designed the study and wrote the protocol. Authors Oslin and Cary undertook the statistical analysis, and author Oslin wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All other authors declare that they have no conflicts of interest.
Acknowledgements
We thank Dr. Candice Walker, Ms Lindsay Nelson, and Ms Jane Decker, who kindly managed the study and oversaw all aspects of data collection.
References (37)
- et al.
Mu-opioid receptor binding measured by [11C]carfentanil positron emission tomography is related to craving and mood in alcohol dependence
Biological Psychiatry
(2004) - et al.
A daily diary study of late-life depression
American Journal of Geriatric Psychiatry
(2006) - et al.
Importance of subsyndromal symptoms of depression in elderly patients
American Journal of Geriatric Psychiatry
(2005) - et al.
Recent advances in the treatment of alcoholism
Clinical Neuroscience Research
(2005) - et al.
Covariations of emotional states and alcohol consumption: evidence from 2 years of daily data collection
Social Science & Medicine
(2007) - et al.
An evaluation of mu-opioid receptor (OPRM1) as a predictor of naltrexone response in the treatment of alcohol dependence: results from the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study
Archives of General Psychiatry
(2008) - et al.
Does affect mediate the association between daily events and alcohol use?
Journal of Studies on Alcohol
(2000) - et al.
Psychometric properties and validity of the obsessive–compulsive drinking scale
Alcoholism: Clinical & Experimental Research
(1996) - et al.
Effects of naltrexone and nalmefene on subjective response to alcohol among non-treatment-seeking alcoholics and social drinkers
Alcoholism: Clinical & Experimental Research
(2004) - et al.
Pharmacogenomics: translating functional genomics into rational therapeutics
Science
(1999)
Alcohol craving predicts drinking during treatment: an analysis of three assessment instruments
Journal of Studies on Alcohol
Psychometric properties of the Penn Alcohol Craving Scale
Alcoholism: Clinical & Experimental Research
Stress and alcohol consumption in heavily drinking men: 2 years of daily data using interactive voice response
Alcoholism: Clinical & Experimental Research
Validity of the Obsessive–Compulsive Drinking Scale (OCDS): does craving predict drinking behavior?
Alcoholism: Clinical & Experimental Research
The PHQ-9: validity of a brief depression severity measure
Journal of General Internal Medicine
The factor generality of brief positive and negative affect measures
Journal of Gerontology: Psychological Sciences
The role of depression in the association between self-rated physical health and clinically defined illness
Gerontologist
The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability
Journal of the American Geriatrics Society
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