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Brstuk jourrsal of .lddutio+s (1987) 82, 31-36 I I I I I I I 1 I I I I I I Use and Misuse of the Concept of Craving by Alcohol, Tobacco, and Drug Researchers LYNN T. KOZLOCCSKI, Ph.D.11 & D. ADRIAN WILKINSON, D.Pbil.'-3 'Departntent of Sociobehamousa! Research, Clinical hutiruu, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada MSS 251, 'Departmesu of PrycholoD', Universtry of Toronto and 'Deparrment of PrycholoCv, York Ustiversiry, Dosinmetr Summasy `Crarnnl' u fou,d in common usale as well as uckstual jarjon. In ordinary use, tke term refers to ssm+r; desne or inrense loqtnj. Recently tke meantpq of the ucltmual urnr 'craetsg' Aas been snetchsd to include all dicposuurns of depestdenr persoru to ssu the addiaive substance. Some nuankers kave fisrtker ezuxded the term to include disposu:oru to avoid the substance. We artsu tltat the mismatch bestree:< the currhu technical a.te of 'csan»t' assd us sw in ordinary IastrucKe is p+obientaru and mukadist; isr many cesus. Esammano+r of tlee lstnanne oR 'csatnsK' reeeals that the eseruy Jtas been co+ecepdsaliud in a oareety of a•ays, each tsYth ssRpluarsores for rscuabls research reckscfques. Whatever the model of 'aaving; we rrje sctemtuu to be csrcus+upeu in tlteis acse of such a loaded term and to sue u osely for 'uroq destns' to take drtgs. To do otlterQVU cass 1<ad aut/tors to make seore of tlua findsstjt than ss;ould be supported by a more caunosu use of avrds. _ Background Scientists soaseutaes spot a perfectly successful word in lively use outside the laboratory, frab it by the throat, dmg it back to the laboratory, and put st on display as a'technscal term'. The word may need special trunin; to beba.e itsslf in the halls of scsence and in the aunds of scsenusts (wbo may have to unlearn the prior uses of the word). 'Craving' has continued to live in the common lantuaie, while being asksd from tsme to tsme to do service in formal ceseueh on drug use. Almost any non-tecbascal dsctuonaryr defiaea 'cranni' as 'a strong desire oc intense lonSta='.1 Clearly, in ks colloqussl uses 'era.uu' eefers to intense deurts for somethsntt. 'Crasn;s' are simply, by aaoat non- technscal de5nstions, a subset of desuss or urges that have crotaed a subrects.e t~reabold of intensity. In 1954 the Expert Cotamittee on AlcoWl and the Expert Committee on Mental Health of the World Health Organization met specifically to clarify the use of the term 'cravtni' in research on alcohol use.~ When the word went into this meeting, its vetaacu- lar use ('urgent and overpowering desire', 'umis- tsble impulse') was clearly appreciated. In addsuon, more techaxai de8astsons were advanced, such as 'witbdrawal symptoms'. Furthermore, two types of aaani were indicated: 'phpucal craving for alcohol (wttbdnwal symptoms)' and a 'symbolic cravmt', defined only in contrast to 'aon-symbohc' phnicai craving, but of great importance since it was thought to be responsible both for the snanauon of escesss.e drinking and for relapse. As a result of the meeting, the experts agreed to excuse 'craving' fi'om techascal urvue: '. .. a term such as 'craving' with its everyday connotations abouid not be used in the scsenu5c literature to describe (certain kinds of alcoholic drinking behav- iourJ if confusion ia to be avoided.' (WHO,19SS, p. 63).' The panel seemed to prefer the tertzs: 'pbyskal 31

r I I I I I I I I I I I I I I I I I 32 Ly+ni T. Kczlo¢t/a 6 D. Adr,sn R'iLevuon dependence' and 'patholopcal desire' as subsututes for 'pbysicai' and 'syctbolu' craving. Despite the advice of the WHO panel, various techniul uses of 'craving' persisted. Indeed, it was notably revived in 1960, when Jellmek, one of the WHO experts above, published Tlu lkuau Corsupr oJAkoRolum.' Therein he laid out, almost verbatim, the dual nature of 'craving' wlvch he had previously described in his preparatory working paper for the WHO group. In other words, Jellinek seems to have ignored the summary statement of the WHO committee of whicb be was a member and simply reverted to hu own prior view on the use of the term 'craving'. (He does reproduce the summary state- meat from the WHO Committee in hu book, but it appears that his indrvidual opanion remained unmo- dified. ) More recently, in 'The concept of craving and its meuurement,' Raakin n al. have tried to rehabili- tate the term for use in behavioural studies of alcoholism.' They described that as the result of the WHO meeting, 'craving' ••as applied to physualiy based rather than psycbologtcall7c based alcohol- seeking behaviour. (T6ough this interpretauon of the history may be correct, it should be noted that those who were responsible for these consequences of the meeting must have either disregarded-as did Jellinek-or been ignorant of the summar7 opinion that closed the commrttee teport.)' Rankin a al. noted that 'craving' became an imporant pan of the medicaJ model of alcoholism and that "new ap- proaches snd challenges to the medical view were soon calling for the overthrow of the concept of cravtng." (p. 389). Operationally, the ttaat.tn rt al. experiment was consistent with Jellinek in etstrtcun; the study of 'craang' to what the WHO comauttee had consi- dered under the rubric of 'pbysual uavtni; i.e. as "an imputed drive state acu.ated by the mtsoduc- uon of alcohol into the system." Raakan a aL noted, however, that the tlleged disuaction between the physical and psycholopal bws of dtsak-saeking bebaviour a probably a"grou o.er•simpli5cauon". In the matter of word selecuon, although Rankin a alL acknowled;ed the "emott.e connotat~ons of intensity aad panic" that accompaay the wacd 'craaag', they retected the use of more inclusive and neutrai terms ('desue for aScobol,' 'dispostuon to drink'), wbrk ezpliatly wishr.ng to a.oid endorse- ment of the medical use of 'crann='. T3ey wrote: ". .. csartag, as currently used by us, is qnonymotu with other labels ... like dispounon to drink, etc." (p. 390). In other words, they chose to try to subdue a much-misused scienttfic term and a volatile (but clearer) common word, by stretchtn; 'craving' to mean the more general concept 'disposition to drtnk'. In an earlier article, these authors ezplained: "We will use craving in the same way that psychologists often use the label 'fear,' i.e. to refer to a mulu- dimensjonal construct involving subjective, behav- ioural, and physiological response systems whuh are partially coupled." (Hodgson er al., 1978, p. 344). They went on to describe a case of 'high craving' and, at the other eztreme, a condition of 'very slight uavtng'. We regset that they did not avoid 'craving' as a term for 'disposition to drink'. One can easily add modifiers to terms like desires or urges and talk about more or less intense urges (the more intense perhaps being called craving). But to use 'craving' to stand for all urges to use a drug is not analogous to the use of fear as a generic tersn. U stng 'cravtng' a thus way is akin to using 'terror' or 'dread' as generic terms for tear. Although all tetror is feu, not all fear is terror. Sunilarly, all craving ss dtspouuon, and not all duposinon is craving. To make a~echaieal meaning of craang tnto a synonym for ail levels of desire courts muunderstaading. There is a ballisuc quahty to usid; words, espeti311y charged words Like 'craving': if one fires 'craving' into a sentence, it may be tmpossible to call back the connotauons before they have done their dama;t. Proper Usa for Cra.ini Cravtq as an F.:plavatiorc of Drfnkrnj or Relapse FoUowtng Mello' and :1lulatt,' we agree that it is not a stusfaetory scsenu5c strategy to e:plain drtnking, relapse, or 'loss of control' by invokuig 'craang' as a causative factor. Tautology under the guise of ezplanation is str!U tautology. To use 'craang' to ezplun drtnking makes the ttustake of e:pecang too much of the term. lNariatt does not inust on the removal of 'craving' from the rsseu- cba's or cliaieiaa't lssicon, but be does want to restrsct its use: "Use of the term should be limited to pbenomenolopcal descriptions of the sublecu.e desire for skobol espersenud by addicts undergoing wstbdrawal. In this context, it would be more aseurue to speak of crasng as a:trong desire for the alleaation of unplamnt withdrawal symptoms .. Although tbere is no scieau5c evsdence to support the assumption that craving is an important determinant of rsLpae, the fact that some alcoholics be/iene dus to be the case may have important I

0 , T7u Co+uepc of Cr¢osM1 33 I I I I I I I I I I I I I I I I effacu on their beha.iour." (titarlatt, 1978, p,289).' Qe share Mariatt's desire to hmit the use of 'craving' to strong desires for alcohol (or other drugs), but we see no need a p+ion to restnct the term to withdrawal-based desires. A, conceptual model of bow 'physical' and 'sym- bolic' craving could be subsumed under a single s process wts advanced in 1974 by Ludwig er al. ' who proposed that craving for alcohol, leading to relapse, was based upon a sub-cluucal conditioned with- drawal syndrome. Thu formulation was interestmg because it offered an e=planauon for the phenome- nologual espersence of craving even after long penods of abstinence. The general notion that craving for alcohol and other drugs may result from conditioning processes has been elaborated both experimentally and theoreucally, based on the demonstrations of the role of conditioning in tolerance. • • R'e think that researchers, sbould_be encourased to reserve the use of the term 'craving' for spec~al, cases of 'urges' to use a drug (e.g. Wilkinson & Le Breton, 1986).' If it should prove that high intensity urges for drug use do not demand aay special treatment (conceptually or therapeutically), then we would even more strongly recommend the use of more general terms such as urge or desire. Thu may have the added advantage of being congenial with the current hypothesis of a conunuum of alcohol dependence (and dependence on other drugs) pro- posed by Edwards et al.', as distinct from the 'change of state' ideas in which the term 'craving' sometimes has its scientific ortpns. Cravue j ar a Sybjec:a,r Pkewo"teaox Perhaps it would be helpful to consider what drug users say about crartng (cf. Ludwig & Stark, 1974 and Chaa n aL, 1964)."" We believe that parc of the e:planauon for the t'esilience of cravmg as an important construct in the study of drug depen- detsce is that in the phenomeaology of dntg dependence sttvng urges to use a drug during penods of absttnence are a central fature of the condition. Clients themselves disungtusb between mild tuges to use a drug and'crasags' to use a drug. A mild urge can be a.ague and very persistent ;achastion that is slmply an attrsbtste of conscioas- ness. A'ca.ing' can be a st:vo;, sudden, srtuation- allT-spect6r . , sotDK"+wk U0e=yMet sm cultvrally snapproprsate, urie speci5cs117 to. eajW in the dtug-tstiag benasour. Cues iadiauag the avul- abtlrty of the drug are powerful and reliable elicitors of the sublecuve state of 'craving'. ' Ludwig & Stark (1974) asked 60 alcoholics "to define craving in their own terau." All but one (98%) could give a definition (78% reported having e:penenced craving). The authors ciusified re- sponses as either. (1) 'cravtng' in terms of achieving desired effects of dnaking or (2) 'craving' in terms of a need or desire for alcohol (with no specification of or mention of desired effects). Ludwig & Stark argued that the e:penence of 'craving' should be regarded as a "conditioned 'cognitive label' which becomes automaucaily attributed to most dysphoric emotional states either tnternally or externally induced. It alerts an alcoholic to his physiological and subtecuve discomfort and permits him to direct hu behaviour to a source of potential relief- the usgesuon of alcohol" (Ludwig & Stark, 1974, p. 904 ). This passage should remmd anyone uamed•4n socul psychology of the considerable research on the effects of cognitive labelling on the perception of biological states.,' -• Pennebacker emphasizes how percepttul scbeaus, selective search, and inferences can tn9uence the perception of the same physical evenu. ' The difference between those alcoholics above who 'uaved' a drink and those who 'craved' a druah to cure their ills may be better understood as the result of different explanatory labels being placed on quite stmilar underlying states, rather than u the expression of fundaatentally different kmds of 'craving'. era.ing La DSM III It IT tastznstz.E tuTook at the place of'cravsng' in the drug wttbdrawal syndroases included in the Dusiaostic and Statuucal Manual of tilenul Dis- orders of the Amencaa Psychutstc Auouauon (DSM III)." DSM III does tsor trouble itself with definitions of 'crartnS', iad lt does not presentany di~cs~suons oT issues involved wuh the use of the term. Table 1 sbowf. *. use ofrwv}nc' ia.the accounts of the five drugs that are said to have withdrawal syndromes. Essentially, in DSM III 'csavint' caa occur as one among various symptoms .ntbsa a withdrawal syndrome, although 'cra.ytsj' appeats amotsg the uplxu 'diaiaosuc cruerus' for a wstbdrawal state only ia the csse of tobacco. The .rssbdrairal syndrome for robscro is siafislar among tboie aescrseed faa the subiecu.nty of ia symptoms (see Table 1). I

I I I I I I I I I I I I I I I I 34 cy+hs r. Kost=skr & D. AQrt.an R'ilkat,totr Table 1. Crsome and R'ukd,asa! Sv,,,yromr ir GS.q !ll Ctsvus; mentioned in tea Ctsvusg an duinosuc criterta Subrecuve symptoms' 'a (Total.\) :Ucobol No No 29 (7) Barbiturates No No 29 (7) Optoids Yes No 0(11) Ampbetaaune No No 50 (4) Tobacco Yes Yes 1S (8) • Q'e use the terms subtecuve aad obrecuve anstead of ps,rcbolog,cai and'pbyswl'' the subx-,uve ejfects may be no less b1ologtcal than the ob*cuve ones, we tnay, stmaly lxk the procedurCS fol mea*~~ them as, b~lqt{cal events 'Cnviag' is first on tae t+acot 4apoo.uc cnursa for tobacco withdrawal. Some Esamples of Cra.in; in Tobacco Resear- chers The SkijJSnarr-lcrvuk Crs-n nt 4a1t Gtv« me central role of'cravtng in the diagnosts of the tobacco withdrawal syndrome, the empirical basis of the apphcauon of this term to smokers is of considerable interest. A much-cited study of smok- ers purportedly concerns 'cravtni'. This work by Shiffman & Jarvtk-' was cnucal to the tnstallauon of the tobacco withdrawal syndrome alongside other drug withdrawal syndromes tn DS4! III.' Seven questions on the Shiffalan-Jarvtk Ques- uonaure were used to measure 'cravtng': (1) "If you could smoke freely, would you like a cigarette this minute?", (8) "If you had just eaten, would you want a ctgarette?", (10) "Are you thtnlung of cigarettes more than usual?", (14) "If you were pernutted to smoke, would you refuse a cigarette right noa•%" (negative loadLtLg), (17) "Do you truu a cigarette?", (20) "Do you have an urge to smoke right now?", (22) "Would you find a clgarette unpleasant right now?" (negative loading). All quesuons were answered on a 7-potat bt-polar scale, labelled 'very de5nltely', 'definitely', 'probably', 'possibly', 'probably not', 'deSnitely twt', 'very definitely not' (scored 7 to 1, 4 - neutral). Note thst not all of the 'craving' questions are very dlrectly related to urges to smoke. One can miss a cigarette without having an urge to use one (reget is not necessaitly the same as desus: ask a divorced person). One can find a ciprette unpleasant right now because at would spoil an attempt to go without cigarettes, and so on. Only two of the questions seem unambiguous as measures of desire or urge to smoke: questions 20 and I. The researchers found a mean 'aa.iag' sco:e of 3.25 in totally abstinent subiects over 2 weeks, indicating that these 'craving' sub;ects 'probably not' had an urge to smoke cigarettes. The mean scores for this group ranged from 4(posstbly want a ciguette) in the fint 2 days of absuaen,:e to 3 (mild destre not to smoke or negative cravyng?) at the end of the two weeks. Their highest 'craving' scores came from partially abstinent subjects (mean- 4.S8), indreaung they 'probably' had an urge to smoke. The wkher: "ew ta he tseapng 'craving' as a continuum that raajes from svers=o+u to use agarettes to urtes to use ciqarettes. Does one who finds a cigarette 'probably unpleasant rtght now' 'crave' ti cigatette more than one who finds a ctgarette 'definitely unpleasant rtght now'? We doubt it and would argue that terms like 'urge' and 'disposition' are better able to tolerate 'negative loadings'. Craantr in .Scfssstt Rather than provide a list of the many graphs, tables, and titles we have seen contuning the word 'ctavtng', we wt1J discuss only one other prominent example. Glusman rr al. published an article in Scltsu,3 'Craving, smoking withdrawal, and cloni- dine'. These researchers found that clonidine re- duced 'craving'. Actually their quesuon did not ask about 'craving', but rather "thlnkiag about ctga- rettes, wish to smoke". Glauman er ai. in their discussion state: "the most consistent w;tbdrawal symptom is craving, by which we mean a preoccupa- tion wtta, thoughts about, or an urge for, the habttuating substance, not necessarily associated with any physical dsstress" (Glusnun tr al., 1984, p. 866). They go on to write: "Craving is the eulxst, the most conslstent, and the most severe symptom of tobacco withdrawal" (Glassnsaa tt aL, 1984, p. 866). Imagine the lmp.ct of this statement if it were based upon the actuaJ variable measured instead of the authors' interpretauon: "Thinking about ciprettes (or wtshing to attioke) u the earliest, the most consutent, and rht xwu severe symptom of tobaeco withdrawal" [emphasis addedj. It is easy to believe that a smoker w.bo h,joing without ctpreettes wonld ezpersence inaeased ddtnttiag about c>;arettes or maessed wuhtnr to smoke. i'betber mae tbouihts are 'aaving' or aoa- trssai a far from certam. (Despite our crttutsms, we do thlak that the eesults of this study are interesnng and that they may have shown important effects on urges to smoke; we are doubtful, bowe.er, I

I I I I I I I I I I I I I I that they have used the term 'craving' to its best advantage.). Four &kensartc .Nodelr of Crarsnj It might be helpful here to try to summarue the major models of 'cravsng' that we have encountered. Figure 1 A represents the Jellinek model in whuh 'cra.'tng' and physical symptoms constitute 'physical dependence' Figure 1 B simply depicts 'craving' being ttie result of physical symptoms. Thss model wu implicit in early research on optotd use- and seems explicit in Mariatt's use of 'cravtng'.' Figure 1 C shows 'craving' as one among various symptoms; this is consistent with its use in the Tobacco Withdraa•al Syndrome as described in DSM III. ' Finally, in Figure l D, we show the more elaborated model of 'craving', dependent to a great extent on the work of Ludwig & Wikler. 'Cravtng' here is seen as a subset of cognitive processes, susceptible to modtficauon by both internal and external cues. We think that it is most useful to consider 'craving' in terms of thss last model, but we recognue that wtthsn thu model there uv ao tuatant+en that cravtng' has ga =potuoLtelauonshtv to anx of the behavtoural phenomena (e.g. relanse) a;soeiated with arug use. The method used to assess 'cnv tng' should clearly be influenced by the conceptual model adopted by the investigator. For esaa'iple, if 'cnv- tng' is viewed as a subjecuve state associated with specific interocepuve or e:terocepuve cues, it makes lsttle sense to subtect persons to quesuon- tuires on 'craving', unless the cues were deliberately mmpulated (e.g. Rankin er at., 1979 and Hodgson cr al., 1978) or unless the subjects were asked to monutor vartauons in the presence or absence of 'craving' over time (e.g. Wtlktnson & Le Breton, 1986)! On the other hzand, if 'craving' is viewed simply as one of the array of withdrawal symptoms that decay monotonscally as a funeuon of the duration of abstinence, then fixed interval quest:on- natre completion (e.g. Shtffman & Jarat, 1976)" ttught seem an appropriate method. Uafortunately, most investigators employing the arm have so explicit tbeoseual postuoa oc the nanue of the beut they purport to assess. As we have indicated earlier, we think that the proper basis for the development of such hypotbeses bes in the careful phenottunolopcal descnpuoo of the subiective state. The ideal in pheaotaenolopcal analysis u to avoid preconcepuotu that would 'lead the wtmess'. Thus, the manner in which orx Tke Cortcept of Craving 35 s-roeonn ) o.o« e.~c. , td) A, , G Figure 1. Sckemasu rrprnetetattopi of Joyr ;oRcepnoes of 'craotsrj'' explored the nature of 'craving' should not indicate belief in the existence of the entity and should certunly permit alternative descriptions. Asking Bktter Questiona One msiht suppose that much of the craving problem could be solved by asking drug users direct questions about craving (e.g. "Do you crave a cigarette right now?" "not at al.l" to "definuely"). After all, we have suggested that drug users do have an apprectauon for the term. Such direct questions may belp matters, but we thsnk that if a'cravtng' question is the only one on which the individual can express a desire for a ctgatene, the drug user may be forced to devalue the meaning of craving, in order to be able to pve an answer. To deal with this, we suggest that direct questions about 'wanting to smoke (or drink)' should be asked at the same ume. Having a few questions on 'urges', one or two of them on craving, seems destrable. West a att~ have used a five item 'craving' quesuonaaur that does have the vtrtue of asking a direct quesuon on 'craving', but, unfortunately, it also confuses the dispositional issue by asking questions on the dsfficult,v of going without ctga- renes, on thoughts about ctgarettes, on bow much cagarettes have been m,ssed and on the awareness of not smoktng. Only a ungle sumsaury 'cravtag' •core is diseusaed .. I

I I I I I I I I I 36 LyR,r T. Kcslasrkr & D. .ldrtcsr rY-cGEmsot3 4 Semantlc Quibble or Consumer Protection One mght.wtsh to dtsnuu our comments as merely ungenerous equivocation. We think that such con- ceptual matters are, on the contrary, very serious to the development of a better understandia6 of drug s.ektng and ta". Tbe use of 'cnvtnR' to stand for all subtec,>.tvep u_*te.t.to use a druLcAn be dang1rpusly close to the maki4 pf _e;aggervted ciaums about one's work. It is akin to the 'batt and switch ucuc', so deplored in applunce sales: luring the consumer into an arucle on the promise of some news about 'cravtng', but, alu, having tn stock only small effects on weak destres to use a drug. Furthermore, such desues and thoughts may not only be less poYs' and_ pre-occupytag interesting thau. 'c,ra thoughts, tbey may in fact be trivtai and of titSugrole cltntcal or scicnu= interest. I or receatly abstuaing drug users to be having thoughts about and mild desires to use their drug of choice may signify lsttle more than the absence of gross memory defictts, ta that these individuals still remember that they used thss drug and that they an striving not to, despite the pleasures it brought them. Ackno..ledBemeaa I'hss work was supported in pssrt by NSERC Grant No. A1436. The opinions expressed are those of the authors and not necessarily those of the Addiction Reseucb Foundation. Refereaces 1. FowLu, H. W & Fowttst, F. G. (Eds) (1%4) 2. Coww Osford Dtcrsowry (Oxford I:nteenttr Press). WHO EzruT Coaws'tTtu ox MtrrTAL HturH AND Ox AtcattOt. (1955) T1e 'cravus8' for akobol, Qstarrs+ty loacrwa/ aJ Srndus ow Akokol, 16, pp. 3 3-.bb. 3. JttitxtJt., E. M. (1960) TAe Dueau Cowcere of 4. Ako/toluwc (New Ha.ea, FWlhotsse Press). RANsw, H., HoocsoM, R k SroatRS.c, T. (1979) I S. . The concept of craving and w sssessuremeat, BrMa- vtor Reseoseh & Tke*apy, 17, pp. 389-396. 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