An in vivo study of the relationship between craving and reaction time during alcohol detoxification using the ecological momentary assessment

Context and craving among individuals with alcohol use disorder attempting to moderate their drinking

Many individuals with alcohol use disorder (AUD) prefer a goal of moderation, because they do not see their drinking as causing severe enough consequences to merit abstinence. Given that individuals attempting to moderate will continue to put themselves in contexts where drinking occurs, understanding how distinct external alcohol cues prompt craving is important for implementing the optimal treatments for individuals with AUD. Using data from a randomized controlled trial of stepped care brief interventions for AUD, this study explored the relationship between drinking contexts and craving in individuals attempting to moderate their drinking using ecological momentary assessment (EMA). At baseline, participants were asked to prospectively identify drinking contexts that were particularly likely to elicit intense craving and heavy drinking, called highly valued drinking contexts (HVCs). During EMA, participants were asked to report three times a day (morning, afternoon, evening) on their non-mutually exclusive contexts and their level of craving. Using multilevel modeling, all drinking contexts were tested as concurrent predictors of craving across the 84 days of the study. Next, AUD severity was tested as a moderator of HVC on craving. Results demonstrated that being in an HVC corresponded to greater reports of any craving and intensity of craving, over and above the influences of several other contextual factors (e.g., negative affect and already drinking). AUD severity significantly moderated HVC's impact on any craving, such that greater AUD severity potentiated HVC's already high odds of any craving. Implications for treatments for individuals with AUD are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predictors of Daily Adherence to Naltrexone for Alcohol Use Disorder Treatment During a Mobile Health Intervention

Background

Adherence to medications for treating alcohol use disorder (AUD) is poor. To identify predictors of daily naltrexone adherence over time, a secondary data analysis was conducted of a trial evaluating a mobile health intervention to improve adherence.

Methods

Participants seeking treatment for AUD (n = 58; Mage = 38 years; 71% male) were prescribed naltrexone for 8 weeks. Adherence was tracked using the Medication Event Monitoring System (MEMS). In response to daily text messages, participants reported the previous day's alcohol use, craving, and naltrexone side effects. Using multilevel structural equation modeling (MSEM), we examined baseline dispositional factors and within-person, time-varying factors as predictors of daily adherence.

Results

Naltrexone adherence decreased over time. Adherence was higher on days when individuals completed daily mobile assessments relative to days when they did not (odds ratio [OR] = 2.53, 95% confidence interval [CI] 1.61 to 3.98), irrespective of intervention condition. Days when individuals drank more than their typical amount were related to lower next-day adherence (OR = 0.93, 95% CI 0.88 to 0.99). A similar pattern was supported for craving (OR = 0.88, 95% CI 0.79 to 0.98). Weekend days were associated with lower adherence than weekdays (OR = 0.71, 95% CI 0.58 to 0.86); this effect was partly mediated by heavier daily drinking (indirect effect = -0.02, 95% CI -0.04 to -0.003) and stronger-than-usual craving (indirect effect = -0.01, 95% CI -0.02 to 0.00) on weekend days.

Conclusions

The results further demonstrate the need to improve adherence to AUD pharmacotherapy. The present findings also support developing interventions that target daily-level risk factors for nonadherence. Mobile health interventions may be one means of developing tailored and adaptive adherence interventions.

A review of EMA assessment period reporting for mood variables in substance use research: Expanding existing EMA guidelines

Ecological Momentary Assessment (EMA) is an increasingly popular approach in substance use research for capturing reliable, in-situ, self-reported information about fluctuating variables, such as mood, over time. Current EMA guidelines do not sufficiently address the reporting of assessment periods (e.g., right now, past 30 min). Given the importance of time in EMA studies, variation and ambiguity in assessment period reporting risks misinterpretation of procedures and findings. The following study reviewed the methodological reporting of EMA assessment periods in substance use research. A search conducted in PsychINFO and PubMed using the terms "ecological momentary assessment" OR "EMA" AND "mood" AND "substance use" yielded 36 unique search results. The references of these results were hand searched and resulted in 126 additional studies. After deleting duplicates and applying inclusion criteria, 56 studies were included in the review. Review of these studies illustrated (1) variability and ambiguity in study assessment periods (2) within-study incongruence between assessment period descriptions and associated EMA prompts, (3) and a large temporal range of retrospective assessment periods across studies. Each of these findings are illustrated and discussed using examples from the literature. From these examples, assessment period reporting guidelines are proposed to improve EMA reporting clarity. Such improvements will facilitate increased synthesis of EMA research and position future researchers to investigate the validity and reliability of EMA data captured with different lengths of retrospection.

Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research

Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.

Comparisons of Alcohol Consumption by Time-Line Follow Back vs. Smartphone-Based Daily Interviews

This study compared alcohol consumption data collected through daily interviews on a smartphone with data collected via the Timeline Follow-Back (TLFB) during a 6-week pilot study of a smartphone-based alcohol intervention system. The focus of the study was to assess for discrepancies between the two measurement methodologies on commonly utilized alcohol outcome variables. Twenty-five participants between 22 and 45 years of age and were drinking heavily at study incipience completed a 6-week alcohol intervention delivered by a smartphone application that monitored drinking through a daily interview. Participants also completed a TLFB of their alcohol consumption during the intervention period. Difference scores were calculated by subtracting the average weekly outcome variables derived from the smartphone daily interview from the average weekly outcome variables derived from the TLFB which yielded six discrepancy scores for each of the 25 participants and resulted in 150 observations. Heirarchical linear modeling indicated that the TLFB and smartphone daily interview methods did not produce significant discrepancies over the 6-week interval when examining percent of heavy drinking days and percent of days abstinent. However, discrepancies on drinks per drinking day increased substantially over time, suggesting that it is susceptible to recall bias when assessed by the TLFB. Results also indicated that participants under-reported their drinking on the TLFB compared to the daily smartphone-based assessment. Results indicate that outside of assessing for extreme drinking (binge or no drinking), the TLFB should be used cautiously and that smartphone apps represent a promising method for accurately assessing alcohol consumption over time.

The association between depression and craving in alcohol dependency is moderated by gender and by alexithymia factors

Alexithymia is a multifaceted personality trait that involves difficulties in identifying and describing feelings to others, a poor fantasy life and an externally oriented cognitive style. Alexithymia has been described as a vulnerability factor for mental and physical diseases. We investigated in a group of 158 alcohol-dependent patients (103 men, 55 women) the association between depression and craving for alcohol when these patients were starting a detoxification program, and the moderating impact of gender and alexithymia on this relation. We first found an interaction between depression and gender in the prediction of craving in the sense that only for women an increase in depressive mood was related to an increase in total craving. When examining gender separately, we found that alexithymia factors acted as moderators. For women, the link between depression and craving was strengthened for the ones scoring higher on "difficulties describing feelings". But for men, the link between depression and craving was reduced for the ones scoring higher on "externally-oriented thinking". These findings suggest that in some cases that need to be identified more systematically in the future, the "externally-oriented thinking" alexithymia factor can exert - at least in the short term - some protective effects.

Acceptability and feasibility of a visual working memory task in an ecological momentary assessment paradigm

Neuropsychological performance has historically been measured in laboratory settings using standardized assessments. However, these methods may be inherently limited in generalizability. This concern may be mitigated with paradigms such as ecological momentary assessment (EMA). We evaluated the initial feasibility and acceptability of administering a visual working memory (VWM) task on handheld computers across 1 EMA study week among adolescents/young adults (N = 39). Participants also completed standardized laboratory neurocognitive measures to determine the extent to which EMA VWM performance mapped onto scores obtained in traditional testing environments. Compliance with the EMA protocol was high as participants responded to 87% of random prompts across the study week. As expected, EMA VWM performance was positively associated with laboratory measures of auditory and VWM, and these relationships persisted after adjusting for predicted intelligence. Further, discriminant validity tests showed that EMA VWM was not linked with laboratory scores of verbal abilities and processing speed. These data provide initial evidence on the convergent and discriminant validity of interpretations from this novel, ecologically valid neurocognitive approach. Future studies will aim to further establish the psychometric properties of this (and similar) tasks and investigate how momentary fluctuations in VWM correspond with contextual influences (e.g., substance use, mood) and clinical outcomes.

Ecological momentary assessment in the investigation of craving and substance use in daily life: a systematic review

BACKGROUND

Craving is viewed as a major determinant of relapse in persons with substance addiction, but this association remains poorly understood due to its time-limited nature and the biases associated with retrospective reporting. Ecological momentary assessment (EMA) offers new opportunities to examine both craving and substance use with strong ecological validity by collecting real-time data in daily life. This review examined all published studies using EMA to: (1) assess the link between craving and substance use; and (2) identify relevant moderators of craving among substance users.

METHODS

We searched PubMed and PsycInfo databases up to October 31, 2013.

RESULTS

Ninety-one studies were selected, involving mostly tobacco smokers (73%). A majority of studies (92%) reported a positive relationship between craving and substance use, concurrently and prospectively, and among users with different levels of use for both legal and illegal substances. Results suggest that craving is a stronger predictor of relapse episodes when assessed in close temporal proximity to substance use. EMA data also confirmed the influence of diverse within-person and between-person sources of variation in daily life craving reports.

CONCLUSIONS

This review provides strong support for the link between craving and substance use, and underscores the importance of the timing of assessments.

Alcohol craving in adolescents: bridging the laboratory and natural environment

RATIONALE

Initial lab studies suggest that adolescent drinkers crave alcohol when presented with alcohol cues. Whether this effect generalizes to the natural environment, however, remains unknown, and studies have not examined whether craving predicts drinking among youths.

OBJECTIVES

This study builds on existing research by pairing controlled lab-based cue reactivity assessments (CRAs) with data collected in the natural environment using ecological momentary assessment (EMA) methods. We examined whether alcohol cues evoke craving among adolescent drinkers in the lab and natural environment, and tested the clinical relevance of craving during adolescence by examining the prospective association between craving and alcohol use.

METHODS

Non-treatment-seeking adolescent drinkers (N = 42; ages 15 to 20 years) completed a lab-based CRA followed by a 1-week EMA monitoring period. During the EMA period, youth were prompted randomly throughout the day to record momentary data on craving and contextual factors (e.g., alcohol cues, peers present).

RESULTS

Alcohol cues elicited craving in the lab, and this effect generalized to the natural environment, especially among adolescents with more alcohol problems. In addition, craving predicted subsequent drinking levels in the natural environment.

CONCLUSIONS

This study demonstrates the utility of pairing lab paradigms with EMA methods to better characterize adolescents' reactivity to alcohol cues. Results implicate craving as a clinically meaningful motivator for drinking among adolescents and highlight a potentially important target of pharmacological or behavioral intervention.

Measurement of alcohol craving

Despite considerable research activity and application in treatment, the construct of craving remains poorly understood. We propose that cravings and urges are cognitive-emotional events in time, characterised by frequency, duration, intensity and salience. Commonly used measures of alcohol craving are reviewed, and their strengths and weaknesses identified. Most measures confound craving with behaviours, or with separable cognitive phenomena such as expectancies, intentions, or perceived behavioural control. These confounds have limited our advances in understanding the determinants and consequences of craving. Based on the criteria applied in this review, among the better performing multi-item measures are the Penn Alcohol Craving Scale and Obsessive subscale of the Obsessive-Compulsive Drinking Scale. Optimal assessment strategies are likely to involve daily assessments of peak intensity of cravings, desires or urges and of the frequency and duration of craving episodes. Of particular interest are measures of intensity at times when individuals are at risk of drinking or of other functional impacts from craving.

Ecological momentary assessment in alcohol, tobacco, cannabis and opiate dependence: a comparison of feasibility and validity

BACKGROUND

Despite growing use of computerized ambulatory monitoring in substance dependence research, little is known about the comparative feasibility and validity of these novel methods by substance type. This study compares the feasibility and validity of computerized ambulatory monitoring in outpatients seeking treatment for alcohol, tobacco, cannabis or opiate dependence.

METHODS

A total of 109 participants were recruited from an outpatient treatment center and completed standard clinical instruments followed by 2 weeks of computerized ambulatory monitoring of daily life experiences and substance use.

RESULTS

Individuals with cannabis dependence had the lowest rates of study acceptance (31%) as well as compliance with the repeated electronic interviews (79.9%), while those with tobacco dependence had the highest rates (62% and 91.0%, respectively). Concurrent validity was found between scores from standard clinical instruments and similar constructs assessed in daily life, with no difference by substance group. While no fatigue effects were detected, change in some variables was observed as a function of time in the study.

CONCLUSIONS

Computerized ambulatory protocols are feasible and provide valid data in individuals with diverse forms of dependence, but compliance to repeated sampling methodology may vary by substance type.

Prospective analysis of early lapse to drinking and smoking among individuals in concurrent alcohol and tobacco treatment

The aims of the current study were to examine, prospectively, (a) dynamic changes in affective state, self-efficacy, and urge in the hours before initial smoking and drinking lapses among individuals in concurrent alcohol and smoking treatment, and (b) the extent to which self-efficacy, urge to use, and/or the use of one substance predicted lapse to the other substance. Ninety-six men and women recruited for a clinical trial of concurrent alcohol and tobacco treatment were eligible for inclusion. Only data from those who experienced an initial lapse to drinking (n=29) or smoking (n=32) were included. Two outpatient substance abuse clinics provided concurrent alcohol and smoking treatment on a weekly basis for three months. Ecological Momentary Assessment (EMA) methods were employed over a 28-day monitoring period to assess antecedents to first drink, and a 14-day monitoring period was examined for initial smoking lapses. Baseline and EMA measures of positive and negative affect, alcohol/smoking urge, alcohol/smoking abstinence self-efficacy, nicotine withdrawal, and quantity/frequency of alcohol and tobacco use were examined as lapse predictors. Analyses of EMA ratings controlled for the corresponding baseline measure. Smoking lapse among individuals in concurrent alcohol and tobacco treatment was foreshadowed by higher urges to smoke, lower positive mood, and lower confidence to resist smoking. Drinking lapse was preceded by lower confidence to resist smoking, but only among individuals who reported recent smoking. Concurrent alcohol and smoking treatment should focus on the enhancement of abstinence self-efficacy, positive mood, and the curbing of urges in order to offset lapse risk.

Deficit in brain reward function and acute and protracted anxiety-like behavior after discontinuation of a chronic alcohol liquid diet in rats

RATIONALE

Discontinuation of chronic and excessive alcohol consumption leads to a dysphoric state in humans. It is not known if there are changes in brain reward function after the discontinuation of an alcohol liquid in rats.

OBJECTIVES

The aim of these studies was to investigate the effect of withdrawal from an alcohol liquid diet on brain reward function and acute and protracted anxiety-like behavior.

MATERIALS AND METHODS

The intracranial self-stimulation procedure was used to assess brain reward function, and the elevated plus maze test was used to assess anxiety-like behavior.

RESULTS

Discontinuation of chronic, 12 weeks, exposure to a 6.2% v/v alcohol liquid diet lead to a minor deficit in brain reward function and did not increase anxiety-like behavior. Discontinuation of chronic, 12 weeks, exposure to a 10% v/v alcohol liquid diet lead to a pronounced deficit in brain reward function and increased anxiety-like behavior. Two weeks after discontinuation of the 10% v/v alcohol liquid diet, the rats with a history of alcohol dependence did not display increased anxiety-like behavior. Restraint stress increased anxiety-like behavior in the rats with a history of alcohol dependence, but not in the control rats. Brain reward thresholds were assessed during the chronic 10% v/v alcohol exposure period. During this period, there were no differences between the brain rewards thresholds of the alcohol and control rats.

CONCLUSION

These findings indicate that withdrawal from a 10% v/v alcohol liquid diet leads to a pronounced deficit in brain reward function and acute and protracted anxiety-like behavior in rats.

Computerized ambulatory monitoring in psychiatry: a multi-site collaborative study of acceptability, compliance, and reactivity

Computerized ambulatory monitoring overcomes a number of methodological and conceptual challenges to studying mental disorders, however concerns persist regarding the feasibility of this approach with severe psychiatric samples and the potential of intensive monitoring to influence data quality. This multi-site investigation evaluates these issues in four independent samples. Patients with schizophrenia (n = 56), substance dependence (n = 85), anxiety disorders (n = 45), and a non-clinical sample (n = 280) were contacted to participate in investigations using computerized ambulatory monitoring. Micro-computers were used to administer electronic interviews several times per day for a one-week period. Ninety-five percent of contacted individuals agreed to participate in the study, and minimum compliance was achieved by 96% of these participants. Seventy-eight percent of all programmed assessments were completed overall, and only 1% of micro-computers were not returned to investigators. There was no evidence that missing data or response time increased over the duration of the study, suggesting that fatigue effects were negligible. The majority of variables investigated did not change in frequency as a function of study duration, however some evidence was found that socially sensitive behaviors changed in a manner consistent with reactivity.

Feasibility and validity of computerized ambulatory monitoring in drug-dependent women

AIM

To examine the feasibility and validity of computerized ambulatory monitoring in drug-dependent women.

METHOD

61 women recruited from public substance abuse treatment centers in Montreal, Canada participated in the current study, 84% of whom reported past 30-day polysubstance use. Mood states, craving, and drug use were assessed by standard clinical instruments and by electronic interviews during 7-days of computerized ambulatory monitoring. Feasibility was assessed by examining compliance with intensive monitoring and equipment loss. Concurrent validity was assessed by examining the degree of correspondence of ambulatory data on craving, mood, and substance use with clinic-based assessments of similar constructs.

RESULT

Participants completed an average 80% of all electronic assessments and no data collection devices were lost or stolen. Relationships among mood, stress, consumption, and craving assessed in the electronic interviews conformed to well-established patterns, and evidence of concurrent validity were found between scores from standard clinical instruments and similar constructs in daily life. Center for Epidemiological Studies-Depression Scale (CESD) scores were positively related to sad mood reported during the electronic interviews (p=0.001) and negatively related to happy mood states (p<0.001), explaining approximately 20% of the variance in each mood state. ASI drug use severity scores were positively associated with craving (p<0.001) and substance use (p<0.001), and explained 46% and 30% of these outcomes, respectively.

CONCLUSION

Computerized ambulatory monitoring is a feasible and valid data collection strategy in drug-dependent individuals.

Do acamprosate or naltrexone have an effect on daily drinking by reducing craving for alcohol?

AIM

To explore the effect of acamprosate and naltrexone on craving and alcohol consumption in the treatment of alcohol dependence.

DESIGN

A randomized, double-blind, single-dummy, placebo-controlled trial.

SETTING

Three treatment centres in Sydney, Australia.

PARTICIPANTS

A total of 169 alcohol-dependent subjects were given naltrexone (50 mg/day), acamprosate (1998 mg/day) or placebo for 12 weeks, in conjunction with manualized medication compliance therapy.

INTERVENTION

During the course of the trial, participants kept a daily diary which included the number of standard drinks they consumed and their peak craving for alcohol that day rated on a 0-10 scale.

MEASUREMENTS

Subjective ratings of daily craving and daily drinking for the first 6 weeks of treatment.

FINDINGS

Mixed/hierarchical linear models were employed on an intention-to-treat basis. Analyses revealed that craving was a significant predictor of daily drinking and baseline levels of depression were the best predictor of daily craving. There was no significant improvement in model fit when treatment group was added both in models of daily craving and daily drinking. Daily alcohol consumption was best predicted by a model incorporating baseline dependence and depression scores, and daily craving, entered as a time-varying covariate. However, there was a significant craving x time x treatment interaction (t = -3.365, df = 4413.712, P < 0.001), suggesting that at higher levels of craving drinking was reduced at a significantly greater rate with naltrexone compared to acamprosate.

CONCLUSIONS

Naltrexone had a greater effect on drinking when craving was high. These results support the role of naltrexone in reducing craving when that craving is highly salient. The role of acamprosate in reducing craving was not supported by these findings.

Feasibility of Ecological Momentary Assessment Using Cellular Telephones in Methamphetamine Dependent Subjects

Background

Predictors of relapse to methamphetamine use are poorly understood. State variables may play an important role in relapse, but they have been difficult to measure at frequent intervals in outpatients.

Methods

We conducted a feasibility study of the use of cellular telephones to collect state variable data from outpatients. Six subjects in treatment for methamphetamine dependence were called three times per weekday for approximately seven weeks. Seven questionnaires were administered that assessed craving, stress, affect and current type of location and social environment.

Results

395/606 (65%) of calls attempted were completed. The mean time to complete each call was 4.9 (s.d. 1.8) minutes and the mean time to complete each item was 8.4 (s.d. 4.8) seconds. Subjects rated the acceptability of the procedures as good. All six cellular phones and battery chargers were returned undamaged.

Conclusion

Cellular telephones are a feasible method for collecting state data from methamphetamine dependent outpatients.

Ecological momentary assessment in addiction

Numerous symptoms in psychiatry are subjective (e.g., sadness, anxiety, craving or fatigue), fluctuate and are environment dependent. Accurate measurement of these phenomena requires repeated measures, and ideally needs to be performed in the patient's natural environment rather than in an artificial laboratory environment or a protected hospital environment. The usual paper and pencil questionnaires do not meet these two conditions for reasons of logistics. A recently developed method, ecological momentary assessment (EMA), made it possible to implement these field assessments via ingenious use of various devices (most frequently an electronic diary) coupling an auditory signal with computerized data capture. The subject carries the device with him/her at all times, and data is recorded in vivo in real time. The programming of repeated measures in the form of a Likert scale or pull-down menu is easily achieved. A recall alarm system can help increase compliance. Compared with classical self-report, EMA improves the validity of the assessment of certain symptoms, which are the main evaluation criteria in clinical trials concerning certain pathologies (e.g., craving and treatment of addiction), where measurement was previously liable to bias. This article sets out to present this method, its advantages and disadvantages, and the interest it presents in psychiatry, in particular via three original applications developed by the authors including: measurement of reaction time without the knowledge of the subject in order to test certain cognitive models; use of a graphic solution for the data recorded for functional analysis of disorders; and the use of data collection via mobile phone and text messages, which also enables therapeutic interventions in real time by text messages, personalized on the basis of the situational data collected (e.g., in the case of craving, the associated mood, solitary or group consumption or concomitant occupations).

Alcohol and tobacco cessation in alcohol-dependent smokers: analysis of real-time reports

Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary (ED) assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. ED data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior ED ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model.