Assessing Craving for Alcohol

by National Institute of Health

Craving for alcohol is common among alcohol-dependent people. Accordingly, measures to assess craving can play important roles in alcohol research as well as in alcoholism treatment. When developing or employing craving-assessment instruments, researchers and clinicians must consider numerous factors, such as the specific characteristics of craving to be evaluated, the instrument's psychometric properties, and the timeframe over which craving is assessed. The measures most commonly used for assessing craving in clinical settings are single-item questionnaires, although several multi-item questionnaires also have been developed. Behavioral measures (amount of alcohol consumption or performance on cognitive tests) and psychophysiological measures (changes in salivation, respiration, or heart rate) are being used primarily in research settings. The assessment of craving can have numerous clinical benefits, such as helping the clinician to evaluate the severity of a patient's alcohol dependence, to select appropriate treatment approaches, and to monitor changes throughout a patient's treatment. The role of craving assessment in predicting treatment outcome, however, remains controversial.

The phenomenon of craving has received increasing attention in recent years from researchers and clinicians working with alcohol-related disorders. Scientists have developed several theoretical models of the development, neurobiology, and phenomenology of craving, some of which are described in other articles in this journal issue. Despite increasing interest in this topic, little agreement exists on how best to conceptualize or measure craving. In addition, fundamental gaps in knowledge remain concerning the relationship between craving and actual drinking behavior.

As researchers and clinicians know from experience, craving is a common occurrence among alcohol-dependent people and a frequent topic of discussion in most alcoholism treatment and research settings. Accordingly, measures that accurately assess craving can play an important role in alcoholism research and treatment. This article reviews several critical issues associated with craving assessment and provides an overview of currently available methods for measuring alcohol craving. The article also provides some suggestions for assessing craving in routine clinical practice. Finally, it briefly discusses recent advances that may enhance the understanding and measurement of craving.

Factors Affecting Craving Assessment

Variables Assessed

The accuracy with which various instruments, or indices, measure craving for alcohol and other drugs (AODs) depends to a considerable extent on the type of variables the instruments evaluate. Early perspectives on alcohol craving focused on the subjective nature of craving. That is, craving was viewed as an experience that could only be assessed through the verbal report of the alcoholic. Consequently, the accuracy of most craving indices was limited by the ability and willingness of the individual alcoholic to accurately report his or her personal experience.

More recent conceptualizations of craving have fostered a broader perspective on the nature of craving and, consequently, on sources of data that could provide important information on craving. For instance, most researchers assume that craving among alcoholics is inexorably linked to alcohol consumption and to relapse to drinking in abstinent alcoholics. This perspective considers behaviors related to seeking or consuming alcohol as direct manifestations of craving. Some investigators, however, have challenged the assumption that alcohol-related behaviors directly result from craving on both theoretical and empirical grounds. Therefore, researchers must further determine for whom, when, and under what circumstances meaningful relationships may exist between craving and alcohol consumption.

Instruments that measure autonomic physiological activity1 (changes in heart rate, blood pressure, or sweat gland activity) in response to alcoholrelated cues, such as the sight and smell of alcohol, also have received increased attention in studies of alcohol craving. Instruments that assess such autonomic responses to alcohol-related cues are particularly relevant to theories of craving that postulate a role for classical conditioning.

Psychometric Issues

With the recent surge in interest in the theoretical and clinical importance of craving, researchers have attempted to develop ways to measure craving as well as ways to assess the utility of existing craving instruments. The utility of any craving assessment instrument depends on its psychometric properties; specifically, on whether the instrument reliably and validly measures craving.

The term "reliability" refers to the degree to which items on an instrument yield consistent results. Several types of reliability exist, not all of which are applicable to every type of assessment instrument. For example, test-retest reliability refers to the consistency of results when a subject is tested several times. Because craving is considered a relatively transient state that is expected to differ from one occasion to another, a high degree of test-retest reliability is not necessarily desirable for craving instruments. Other indices of reliability are more important to craving instruments - for example, whether consistent results are obtained with an instrument when several testers evaluate the same person (inter-rater reliability) and whether similar items on a test do not yield inconsistent or contradictory responses.

The term "validity" refers, in general, to the degree to which an instrument measures what it purports to measure. Because the empirical study of craving is a relatively new endeavor, and investigators consequently are still trying to understand exactly what craving is, assessing the validity of an instrument that proposes to measure craving is a difficult task. After more data have been generated and some agreement has been established on what constitutes craving, researchers can more confidently assess the validity of craving instruments.

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.