Sunday, October 27, 2013


"Unlike most of our crowd, I did not get over my craving for liquor much during the first two and one-half years of abstinence.  It was almost always with me......"  Doctor Bob's Nightmare.  Alcoholics Anonymous, Fourth Edition, New York City, 2001, p 181.

Craving to use drugs and alcohol is a common problem.  As Doctor Bob points out in the above quote, craving is rare for alcoholics beyond the acute detoxification phase, but protracted for many other drugs depending on the class of addictive compound and the pharmacological properties of the specific drug.   Apart from the biological determined heterogeneity of response to addictive compounds there are also the subjective aspects.  In order strive for more objectivity, modern psychiatry has established diagnostic criteria for disorders of interest.  These disorders are grouped in categories to seem uniform.  Depending on the criteria of interest there is a broad range of subjective experience and description when describing common problem like anxiety and depression.  Some people don't know the difference between them.  Others have a mixture of both.  Some people are anxious all of the time independent of their surroundings.  Others get depressed or panic only in certain situations.  The interpretation of what a person considers to be a craving is as diverse.

Craving for an addictive drug or alcohol comes in many forms.  It can be a perception of a physical property of the actual compound itself such as the taste, odor, appearance or consistency.  It can be physical acts associated with its use and a common example there is a feeling that cigarette smokers get when they feel like they need to do something with their hands after they stop smoking.  It can be cue induced like being offered a drug or being in a place where previous drug transactions occurred.  It can be recall of the first intense and protracted euphoric experience of using the drug even though that has long passed related to tolerance.  The overwhelming affect associated with craving is anxiety and fear because of the sign on an impending withdrawal or relapse.  The negative reinforcement that keeps addictions going after the initial states of positive reinforcement due to the euphorigenic effects of the drug is avoiding withdrawal.  Craving may be a signal that acute withdrawal is imminent or that there is a state of chronic withdrawal.

Craving has had an uncertain place in the field of addiction and the diagnosis of addictive states, largely because of the broad range of experiences associated with craving.  This diagrammatic summary shows that various groups have considered the definition to be too vague.  In other cases there was no consensus that craving was a universal enough phenomenon to be considered a diagnostic criterion.  That changed this spring when the DSM-5 added craving and eliminated legal consequences of drug and alcohol use as a diagnostic criterion.  Medications used to eliminate cravings probably led to that consideration, but people with cravings are more likely to relapse and have significant distress during recovery.

The addition of cravings to the DSM-5 opens up a whole new area of focus during encounters with people who have addictions.  Prior to this change the two major texts on addiction devoted about 3-4 pages to craving phenomena.  Addiction psychiatrists and addictionologists may have already been focused on this area, but I think that overall it makes ongoing assessments more dynamic because it is an intervention point for physicians and there are a number of medical and non-medical interventions that are possible.  Omar Manejwala, MD reviews the options in his very readable book entitled Craving.  This book is interesting because it gives a number of practical tips on how to counter cravings based on the substance involved as well as the importance of psychosocial interventions like 12-step recovery and how that might work.  Addiction science has probably been at the cutting edge of neurobiology for at least the past decade and with this focus there is often the implicit understanding that we are searching for some medication that will be an immediate solution to craving.  In some cases we have that medication, but I always emphasize that cravings at some point disappear and that there are non medication approaches to addressing them.

George Dawson, MD, DFAPA

Manejwala O.  Craving: Why We Can't Seem To Get Enough.  Hazelden, Center City, MN, 2013.


Neuropsychopharmacology The Fifth Generation of Progress (2002):  Craving is a powerful, "must-have" pull that causes addicted people to risk and sometimes lose, their relationships, families, money, possessions, jobs and even their lives. (p.1575)

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