Assessing craving and its relationship to subsequent prescription opioid use among treatment-seeking prescription opioid dependent patients
Introduction
Craving is a core feature of substance use disorders, as evidenced by its recent addition to the diagnostic criteria for these disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Much of the research on craving has focused on whether it may precipitate substance use and thus serve as a risk marker during treatment. A number of studies have examined whether craving at treatment entry predicts outcomes following treatment, with some studies supporting this association (Anton et al., 1996, Sinha et al., 2011), some finding no association (Ahmadi et al., 2009, Dreifuss et al., 2013), and others finding associations only for particular types of craving (e.g., stress-induced craving; Sinha et al., 2006).
Although self-reported craving may have inconsistent predictive validity for long-term substance use disorder treatment outcomes, several studies have demonstrated that drug craving is associated with proximal (e.g., within the next week) substance use (Hartz et al., 2001, Moore et al., 2013, Weiss et al., 2003). Because craving is influenced by contextual factors such as substance-related cues, stress, and withdrawal symptoms, it may serve as a marker for immediate use, and associations with substance use may weaken over longer periods of time (Shiffman et al., 1997).
The evidence supporting the predictive validity of craving for proximal substance use highlights the value of regular assessment of craving during treatment. Once heightened risk has been identified, providers may choose to implement specific strategies to attempt to mitigate the risk of use in the near future. However, demands on time and resources in clinical settings necessitate that assessments be as brief as possible while still yielding meaningful information. In research settings, efficient assessment strategies have the dual benefit of minimizing participant burden and providing additional time for the assessment of other pertinent constructs. Self-report craving measures vary dramatically in length, ranging from a single item (Connor et al., 2005, West and Ussher, 2010) to more than 40 items (Heishman et al., 2001, Tiffany et al., 1993). Although lengthy, multi-dimensional assessments may be of particular value in certain research settings, the briefest possible measure that still indicates level of risk is preferable clinically and in research settings in which assessment burden is a concern, or in which repeated measures are collected. A previous multi-site study of treatment for cocaine dependence demonstrated that a brief, 3-item craving measure developed by our group predicted cocaine use in the following week, when controlling for current cocaine use (Weiss et al., 2003). It is unclear whether the predictive validity of this measure extends to other substances of abuse.
As the prevalence of prescription opioid dependence has rapidly escalated in the past 15 years (Johnston et al., 2012, Substance Abuse and Mental Health Services Administration, 2012), studies have begun to examine craving in this population. However, the association between opioid craving and proximal opioid use has yet to be examined. A study in chronic pain patients receiving opioids for pain found that self-reported craving for medication was associated with aberrant drug behaviors (e.g., positive urine toxicology) assessed 6 months later (Wasan et al., 2009). Although this study included participants both with and without prescription opioid use disorders, these results suggest that craving for prescription opioids is a risk marker for later opioid misuse, at least among those with chronic pain.
Another reason to examine craving specifically in patients dependent on prescription opioids is the possibility that craving in this population differs in some ways from craving for illicit drugs. A recent report from our group found that craving in response to opioid cues was less robust in this population than in those dependent upon heroin (McHugh et al., 2014). One potential explanation for this difference is that the associative conditioning of prescription drug cues may differ from illicit drug cues because the pairing of drug use and contextual cues is less unique for prescription drug cues, which are encountered in numerous settings (e.g., pharmacies, advertisements). Thus, research examining the role of cue-induced craving in this population is of particular interest.
The aim of the current analysis of data from a multi-site study of prescription opioid dependence treatment was to examine whether craving for prescription opioids predicted use of these drugs in the following week. A brief, 3-item craving measure was used to assess three different domains of craving: general craving, cue-induced craving, and likelihood of use if exposed to an environment in which drugs were previously used. In this study, we examined the concurrent and predictive validity of this measure in a prescription opioid dependent population. We hypothesized that greater craving would be associated with a higher likelihood of opioid use in the following week, when controlling for current use. In an exploratory analysis, the associations between the individual craving scale items and subsequent use were examined to evaluate the relative importance of these three domains of craving. This study is novel in its examination of the relationship between craving and prescription opioid use over brief time intervals, its extension of a validated measure to a new population, and its consideration of the incremental importance of various domains of craving.
Section snippets
Procedures
The Prescription Opioid Addiction Treatment Study (POATS) was a large, randomized controlled trial conducted in the National Drug Abuse Treatment Clinical Trials Network. For a full description of POATS, see Weiss et al. (2010). POATS was conducted at 10 treatment programs across the United States. The study design included two phases. In Phase 1, participants received a 4-week buprenorphine–naloxone taper and were randomly assigned to receive standard medical management (Fiellin et al., 1999)
Preliminary analyses
In Phase 2 of the POATS trial, 360 participants were randomized to a treatment condition. This sample was 42% female, mostly self-identified as White (91%), and many were employed full time on average in the past 3 years (60%). The mean age of the sample was 32.5 years (SD = 9.7) with a mean of 12.9 years (SD = 2.2) of education.
At the Phase 2 baseline visit, participants reported a moderate to high level of craving for opioids; the mean total Opioid Craving Scale score was 6.9 (SD = 2.8, median = 7.3,
Discussion
In this large clinical trial of treatment for prescription opioid dependence, we examined whether craving in any given week during the treatment trial was associated with urine-confirmed self report of opioid use in the subsequent week. The 3-item Opioid Craving Scale total score predicted opioid use in the following week, controlling for current opioid use and a history of heroin use. Each one-unit increase in the score on this scale was associated with a 17% higher odds of using opioids in
Author disclosures
Role of funding source Funding for this study was provided by NIDA Clinical Trials Network grant U10 DA015831 (Drs. Weiss and Carroll). Effort on this manuscript was also supported by NIDA grants K23 DA035297 (Dr. McHugh), K24 DA022288 (Dr. Weiss), and K99R00 DA029115 (Dr. Hill). NIDA 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 Drs. McHugh and Weiss
References (37)
- et al.
Self-efficacy for cocaine abstinence: pretreatment correlates and relationship to outcomes
Addict. Behav.
(2008) - et al.
Patient characteristics associated with buprenorphine/naloxone treatment outcome for prescription opioid dependence: results from a multisite study
Drug Alcohol Depend.
(2013) - et al.
Craving predicts use during treatment for methamphetamine dependence: a prospective, repeated-measures, within-subject analysis
Drug Alcohol Depend.
(2001) - et al.
The development of a cocaine craving questionnaire
Drug Alcohol Depend.
(1993) - et al.
A multi-site, two-phase, Prescription Opioid Addiction Treatment Study (POATS): rationale, design, and methodology
Contemp. Clin. Trials
(2010) - et al.
Predictors of treatment outcome in outpatient cocaine and alcohol dependence treatment
Am. J. Addict.
(2009) Diagnostic and Statistical Manual of Mental Disorders
(1994)Diagnostic and Statistical Manual of Mental Disorders
(2013)- et al.
The obsessive compulsive drinking scale: a new method of assessing outcome in alcoholism treatment studies
Arch. Gen. Psychiatry
(1996) - et al.
Craving and self-efficacy in the first five weeks of methadone maintenance therapy: a daily process study
J. Stud. Alcohol Drugs
(2009)
A comparison of the Yale-Brown Obsessive Compulsive Scale for “heavy drinking” with a single item craving measure: construct validity and clinical utility
Subst. Use Misuse
Self-efficacy and alcohol relapse: concurrent validity of confidence measures, self-other discrepancies, and prediction of treatment outcome
J. Stud. Alcohol
Manual for Standard Medical Management of Opioid Dependence with Buprenorphine
Dynamic self-efficacy and outcome expectancies: prediction of smoking lapse and relapse
J. Abnorm. Psychol.
Marijuana Craving Questionnaire: development and initial validation of a self-report instrument
Addiction
Monitoring the Future National Results On Adolescent Drug Use: Overview Of Key Findings, 2011
Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial
Addiction
Self-efficacy as a predictor of outcome after residential treatment programs for alcohol dependence: simply ask the patient one question!
Alcohol. Clin. Exp. Res.
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