Alcohol Craving Treatment

by National Institute of Health

Although many alcoholics experience craving, researchers have not yet developed a common, valid definition of the phenomenon. Numerous models of the mechanisms underlying craving have been suggested, however. One of those models - the neuroadaptive model - suggests that the prolonged presence of alcohol induces changes in brain-cell function. In the absence of alcohol, those changes cause an imbalance in brain activity that results in craving. Furthermore, the adaptive changes generate memories of alcohol's pleasant effects that can be activated when alcohol-related environmental stimuli are encountered, even after prolonged abstinence, thereby leading to relapse. Similarly, stressful situations may trigger memories of the relief afforded by alcohol, which could also lead to relapse. Neurobiological and brain-imaging studies have identified numerous brain chemicals and brain regions that may be involved in craving. Psychiatric conditions that affect some of these brain regions, such as depression or anxiety, also may influence craving. A better understanding and more reliable assessment of craving may help clinicians tailor treatment to the specific needs of each patient, thereby reducing the risk of relapse.

Many alcoholics, including those trying to achieve abstinence, experience craving for alcohol, often for extended periods of time. Jellinek and colleagues first recognized craving as a central component of the alcohol dependence syndrome. Up until the 1990s, however, other researchers and clinicians did not rigorously investigate this phenomenon. Only during the past 5 to 10 years has interest in craving increased, fueled to various extents by numerous developments, as follows:

Cognitive psychology, which has played an increasingly important role in the investigation and treatment of alcoholism, emphasizes the need for understanding, monitoring, and using alcohol craving as part of a structured alcoholism treatment approach.

Researchers and clinicians have reevaluated classical conditioning1 as a mechanism that may underlie a drinker's response to alcohol-related stimuli, or cues, in the environment (the smell of beer or the sight of a bar); as a result, researchers have developed hypotheses and experimental approaches related to cue-induced craving.

Medications such as naltrexone have been found to reduce relapse among abstinent alcoholics, and some studies suggest that these medications also may reduce craving.

Researchers have greatly expanded the understanding of the brain mechanisms underlying alcohol and other drug (AOD) dependence and of the brain structures that may be associated with craving.

Researchers and clinicians have developed improved instruments for assessing the severity of craving; these new rating scales have greater reliability in measuring and defining craving.

The methods used in alcoholism treatment research have become increasingly sophisticated; as a result, the relationship of concepts such as craving to clinical outcome now can be reliably evaluated.

Despite the renewed interest in craving, researchers and clinicians have not yet developed a common definition of the phenomenon or identified its underlying causes because craving is primarily a subjective experience for each drinker. Without a valid, uniform definition of craving, however, clinicians cannot accurately assess their clients' levels of craving or measure changes in craving that might indicate an improvement or worsening in the client's condition. The lack of a definition of craving also impedes researchers in their investigations of the neurological and psychological mechanisms contributing to the experience of craving. A better understanding of those mechanisms, in turn, could lead to improved behavioral and pharmacological approaches for the treatment of alcoholism.

This article reviews various models of craving that researchers have developed in recent years to explain the clinical phenomenon and underlying mechanisms of craving. In addition, this article describes the brain networks that have been associated with craving as well as the approaches used to measure craving. Finally, the article summarizes the clinical implications of an improved evaluation of craving and provides an outlook on future craving research.

Models of Alcohol Craving

Although the concept of craving appears to be central to the understanding of addiction to all AODs - particularly to the loss of control over and relapse to AOD use - precise definitions of craving have remained elusive. Similarly, no agreement exists among researchers and clinicians on how to measure craving accurately. Nevertheless, investigators have made substantial progress in developing numerous models of AOD craving. Singleton and Gorelick have developed a classification scheme that comprises two general categories of craving models: models based on conditioning mechanisms (conditioning models) and models based on cognitive mechanisms (cognitive models).

Conditioning models are based on the tenets of classical conditioning. These tenets posit that alcohol-related cues (the sight of a bar or a beer bottle), after repeatedly being paired with alcohol consumption, become conditioned stimuli - that is, they elicit the same physiological and psychological response as alcohol consumption itself (release of certain brain chemicals [neurotransmitters]). If alcohol consumption does not occur immediately, these cue-induced responses result in craving, either to experience alcohol's pleasant, or reinforcing, effects or to avoid or alleviate the unpleasant, or aversive, effects of not drinking. Conversely, cognitive models are based on the assumption that responses to alcohol and alcohol-related cues involve various cognitive processes, such as expectations regarding the pleasant effects of alcohol and a person's belief in his or her own ability to cope with the desire to drink. Although some of these models may be more relevant to drugs other than alcohol, many characteristics of craving overlap among various AODs.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.