The Measurement of Craving in Cocaine Patients Using the Minnesota Cocaine Craving Scale James A. Halikas,
Kenneth L. Kuhn, Ross Crosby, Gregory Carlson, and Frederick Crea
Drug craving is an irresistible urge that compels drug-seeking behavior, and which often accounts for relapse among treated cocaine users. A cocaine craving scale that has proven reliable and practical in clinical treatment research with cocaine-using subjects is presented. It assesses intensity, frequency, and duration of this entirely subjective phenomenon. Data from 234 scales completed by 35 patients in treatment showed that craving for cocaine was of variable intensity, experienced relatively few times per day (zero to two), and of short duration (~20 minutes). Internal consistency among the three scales was robust, shown by a standardized item (Yof .826. The use of this scale should allow for each component of craving to be studied separately. Copyright 0 1991 by W.B. Saunders Company
C
RAVING IS A SUBJECTIVE phenomenon deemed a crucial element in the medical and psychological characterization of alcohol and substance abuse patients. While commonly described by patients with many types of substance abuse, it is a poorly documented and inadequately described clinical symptom. Because craving, like pain, is entirely subjective, no adequate external measurement has been designed that can systematically assess the psychological symptom. Craving is clinically of particular importance in certain drug abuse syndromes: cocaine abuse, abuse of the psychostimulants such as methamphetamine, and use of nicotine. The compulsion, or “driven,” quality to the craving that is described by patients habituated to these particular substances, reaches a level of intrusiveness and loss of control not seen in patients who abuse alcohol, sedative hypnotics, benzodiazepines, or opiates. By analogy of intensity and disruption, craving is to desire what panic is to anxiety. The cocaine craving sensation, in particular, can be so intense and intrusive that it disrupts concentration, interferes with performance, makes the individual acutely and extremely uncomfortable, and controls subsequent actions. In short, craving is an irresistible urge to use a substance that compels drug-seeking behavior. Patient reports suggest that cocaine craving may be stimulated by a wide range of internal cues, such as dysphoria or boredom, or by external prompts or triggers, such as cash, needles, liquor, white powder, or other environmental cues that bring to mind previous use experiences. These individual reminiscences may be so vivid and clear that they have been compared with the flashbacks experienced by LSD users in previous decades, or the flashbacks of current posttraumatic stress
From the Department of Psychiatry, Universi@ of Minnesota School of Medicine, and the Chemical Dependency Treatment Program, Universityof Minnesota Hospital and Clinic, Minneapolis MN. Address reprint requests to James A. Hal&as, M.D., Professor of Psychiatry, Universily of Minnesota, Box 393 UMHC, 420 Delaware St SE, Minneapolis, MN 55455. Copyright 0 1991 by W B. Saunders Company 0010-440X/91/3201-0002$03.00/0
22
Comprehensive
Psychiatry, Vol. 32, No. 1 (January/February),
1991: pp 22-27
23
COCAINE CRAVING SCALE
disorder patients. Protracted craving requires months to years to be attenuated and is a major factor in relapse within the first year of recovery.’ While drugs in general, and cocaine in particular, may be used by individuals for a variety of reasons other than craving, the systematic assessment of craving would assist in treatment and clinical research. At the University of Minnesota Chemical Dependency Treatment Program, over the last 2 years, we have developed and refined a cocaine craving scale that we believe to be useful, practical, and reliable when used with cocaine-using patients. This scale has been used successfully on both a daily and a weekly basis in different populations. It has met with good patient comprehension and cooperation. Dackis et al.* and others3.4 have previously described the use of a lo-cm line to measure craving for drugs from absent to maximum. After discussions with several patients about the phenomenon of craving, it was our clinical judgment that craving was more complex than could be assessed on a single dimension. Therefore, we have identified three basic dimensions to the assessment of craving in relationship to cocaine: intensity, frequency, and duration. By repeated clinical probing, it became apparent that patients are able to describe how intense the urge to use cocaine is on different occasions. This also indicated that craving as a phenomenon is episodic, that it waxes and wanes over time. This episodic quality has been previously noted.‘.’ Thus, not only could intensity be described, but also frequency per day or per week could be estimated, and time duration per episode of craving could be recollected. In this regard, craving is analogous to other subjective phenomena, in the range of human experience, such as pain, hunger, drowsiness, and sadness. Based on this information, the original scale was first expanded to three different lo-cm lines, one for each of these attributes. This instrument proved to be unreliable. Patients tended to not differentiate between the different dimensions, marking the same location for all three measurements. When discussed with them, they would acknowledge that the lo-cm lines, anchored by “none” and “a great deal” did not accurately reflect either frequency or duration, although intensity was captured by the continuous scale. The scale was therefore modified to its present format as shown in Fig 1. Frequency and duration are each aggregate estimates that can be separately judged. With this scale, each dimension of craving can be used separately to assess treatment efficacy of new treatment strategies. For example, a treatment may impact the intensity of craving, but not the frequency or duration dimensions of craving episodes. METHOD
Subjects The subjects were 35 patients enrolled in the cocaine treatment program at the University of Minnesota during 1987 to 1989. There were 23 men and 12 women. The average age of the patients was 32 years, with a range from 23 to 46. Two thirds were white (24); one third were black. These were serious drug users. Fifteen of the patients were currently on methadone maintenance; 21(60%) had a history of intravenous drug use; the patients averaged 15.6 years of lifetime drug abuse, and 7.8 years of cocaine use. They had failed in an average of 3.6 previous treatment episodes, excluding detoxification. They averaged 7.1 lifetime arrests and had been incarcerated an average of
HALIKAS ET AL
24
UNIVERSITY Department Substance
OF MINNESOTA
I H III
Study No.
Cocaine
Craving
Scale CCSl
01 Psychlalry Abuse Disorder
Program
Patient No. II
“lslt
Patlent lnltlals
m
No. /ll-
Date [IHIHI
1 On the lme below, please make a mark between “NOT AT ALL” and “A GREAT DEAL” lo w?dlcale HOW STRONG. on the average, your craving for cocaine has been DURING THE PAST WEEK INTENSITY
HOW STRONG HAS AN AVERAGE URGE BEEN:
NONE/ NOT AT ALL
I ,....I
...!
I
!..
I
1.. ,
...!
I
2 Check the box below which best indicates, on the average, HOW FREQUENTLY you have experienced craving for cxaine DURING THE PAST WEEK.
-
FREQUENCY
I
A GREAT DEAL
(how many times a day)
HOW MANY TIMES PER DAY:
00
01
q
02 11-20
[7
Morethan
3. Check the box below which best indicates, on the average, HOW LONG the craving for cocaine has lasted DURING THE PAST WEEK. DURATION cl
-HOWLONG
DOES AN AVERAGE URGE LAST (in minutes):
05 min.
cl
610mi1-1.
0
1%20min.
q
3145 min.
0
21-30min.
0
2 Hr.+
4. Overall, how has your “craving” lor cocaine changed FROM LAST WEEK?
q
lrcreased
cl
q
No clw@?
Decreased
5. How do you think your medication has affected your craving for cocaine DURING THE LAST WEEK? Sorrwvvhat Reed
GMfY Rt?dLCed
0
Fig 1. 19.3 months. These treatment.
Charge
increased
Increased
Copyright 1989. James Halikas. M.D., University of Minnesota.
The University of Minnesota Cocaine Craving Scale.
patients
reported
using cocaine
an average
of 60.7 days in the 100 days before
Cocaine Craving Scale The 35 subjects completed varying numbers of cocaine craving scales, ranging from a low of one to a high of 27. A total of 234 cocaine craving scales were completed by the 35 subjects. The time in treatment for these subjects ranged from one week to 53 weeks.
COCAINE
CRAVING
SCALE
25
RESULTS The results obtained from the cocaine craving scales suggest that craving for cocaine is of variable intensity, is typically experienced relatively few times per day, and is of short duration. The mean intensity rating for craving was 45.12 (SD 30.79). The frequency rating of craving indicated that over 90% of the time respondents reported experiencing craving no more than two times per day, with 15% of the scales (34) reporting no craving, 60% of the scales (140) reporting craving only once per day on average, and 16% (36) reporting craving on the average of twice per day. Similarly, the average duration of craving for cocaine was typically 20 minutes or less, with 44% of the scales (101) reporting an average duration of craving of 0 to 5 minutes, 21% (49) reporting craving of 6 to 10 minutes, and 20% (46) reporting craving of 11 to 20 minutes. The relationship among the three measures of cocaine craving were quite consistent, with correlations of .610 between intensity and frequency, .637 between intensity and duration, and .591 between frequency and duration. A test of validity by internal consistency among the three measurements, the extent to which they all measure the same general construct, was robust, as demonstrated by a standardized item fy of .826. Not surprisingly, craving was found to be positively related to cocaine use. The number of days of cocaine use correlated with intensity (r = .391; P < .OOl), with frequency (r = .451; P < .OOl), and with duration (r = .276; P < .OOl). Craving was also positively associated with cocaine-use dreams. Cocaine-use dreams are the phenomenon of nightmares or disturbed sleep associated with dreams of using cocaine, where the subject awakens with diaphoresis and a feeling of either having just used cocaine or of an intense need for cocaine. The number of use dreams correlated with craving intensity (r = .324; P < .OOl), with frequency (r = .312; P < .OOl), and with duration (r = .230; P < .OOl). Predicting Cocaine Abstinence
Because subjects differed greatly in the number of craving scales completed (ranging from one to 27), that portion of cocaine use variance attributable solely to the number of completed forms (46.6% of the criterion variance; F = 5.58; P < .OOl) was initially removed using dummy coding. A stepwise discriminant analysis was then performed using the remaining predictor variables to determine which, if any, were predictive of cocaine abstinence. Only one variable, cocaine craving intensity, significantly (and inversely) predicted abstinence (F = 7.91; P < .OOl): the lower the intensity of cocaine craving, the more likely the subject was able to maintain abstinence. The correlation coefficient for intensity was .332 (P < .OOl), with the single highest correlation, the canonical discriminant function coefficient, indicating that intensity contributed substantially to the discriminant classification. The final regression equation accounted for 62.7% of the total criterion variance (Wilks’ A = .367; P < .OOl). DISCUSSION
It is admittedly difficult to measure a subjective phenomenon such as craving. However, it is incumbent upon the behavioral science community to attempt to
26
HALIKAS
ET AL
develop instrumentation that can assess such subjective, intrapsychic events, retrospectively, as objectively as possible, in order to accurately assess the success of intervention efforts. We believe that this cocaine craving scale may be of assistance in this regard. It appears that cocaine craving can be separated usefully into three distinct attributes, intensity of craving, frequency of episodes of craving, and duration of each episode of craving, which can be assessed separately. This scale allows for each component of craving to be separately studied. The face validity of this scale is indicated by the correlation between craving and use on the one hand, and absence of craving and abstinence on the other. The internal validity is indicated by the similar levels of correlation among all three items. This scale may prove useful in drug treatment research. For example, the scale can provide a separate validation of efficacy for anti-craving medications as they are developed, beyond self-report of cocaine use, and current abstinence from cocaine use. Such a separate validation is necessary because compliance with any anti-craving medication regimen is likely to deteriorate if craving is not eliminated or substantially reduced.‘-” The Minnesota Craving Scale has the flexibility to be modified to meet the specific needs of those who use it. For example, intensity could be assessed for (1) worst craving episode during the past time interval, or (2) average craving episode during the past time interval. Further, separate assessment can be made of “spontaneous” craving episodes versus “prompted” craving episodes, those craving episodes triggered by external stimuli or memories. All of these appear to be components of craving. In addition, the scale as designed allows assessment of an overall patient rating, or global judgment, regarding severity of craving from one week to the next, or, when modified, from one day to the next, and allows for a global patient rating of the efficacy of any anti-craving medication being tested. This scale can be directly modified for use with any psychostimulant drug of abuse, and could, by analogy, be tried as an instrument for measurement of other subjective phenomena. We conclude that the cocaine craving scale presented in this report may be a valuable adjunct to the assessment of craving in the clinical and research setting for the study of cocaine and other psychostimulant abuse and their treatment. REFERENCES 1. Gawin FH, Ellinwood EH: Cocaine and other stimulants. N Engl .I Med 318:1173-1181,1988 2. Da&is CA, Gold MS, Sweeney DR, et al: Single-dose bromocriptine reverses cocaine craving. Psychiatry Res 20~261-264, 1987 3. Gawin FH, Kleber HD: Cocaine abuse treatment. Arch Gen Psychiatry 41:903-909,1984 4. Gold MS, Redmond DE, Kleber MD: Clonodine blocks acute opiate withdrawal symptoms. Lancet 2:599-602,1978 5. Jekel JF, Allen DF, Podlewski H, et al: Epidemic cocaine abuse: A case study from the Bahamas. Lancet 1:459-462,1976 6. Dackis CA, Gold MS: Pharmacological approaches to cocaine addiction. J Subst Abuse Treat 2:139-145,1985 7. Gawin FH, Kleber HD: Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Arch Gen Psychiatry 43:107-13, 1986 8. Halikas JA, Kemp KD, Kuhn KL, et al: Carbamazepine for cocaine addiction? Lancet 623-624, 1989 (letter)
COCAINE CRAVING SCALE
27
9. Halikas JA, Kuhn KL, Maddux TL: Reduction of cocaine use among methadone maintenance patients using concurrent carbamazepine maintenance. Ann Clin Psychiatry 2:3-6,199O 10. Halikas JA, Kemp KD, Kuhn KL, et al: Preliminary indicators of differential treatment responsiveness to carbamazepine for cocaine addiction, based on differential personality pathology. Biol Psychiatry 25:13A, 1989 (suppl, abstr) 11. Gawin FH, Kleber HD, Byck R, et al: Desipramine facilitation of initial cocaine abstinence. Arch Gen Psychiatry 46:117-121,1989
Kenneth L. Kuhn, Ross Crosby, Gregory Carlson, and Frederick Crea
Drug craving is an irresistible urge that compels drug-seeking behavior, and which often accounts for relapse among treated cocaine users. A cocaine craving scale that has proven reliable and practical in clinical treatment research with cocaine-using subjects is presented. It assesses intensity, frequency, and duration of this entirely subjective phenomenon. Data from 234 scales completed by 35 patients in treatment showed that craving for cocaine was of variable intensity, experienced relatively few times per day (zero to two), and of short duration (~20 minutes). Internal consistency among the three scales was robust, shown by a standardized item (Yof .826. The use of this scale should allow for each component of craving to be studied separately. Copyright 0 1991 by W.B. Saunders Company
C
RAVING IS A SUBJECTIVE phenomenon deemed a crucial element in the medical and psychological characterization of alcohol and substance abuse patients. While commonly described by patients with many types of substance abuse, it is a poorly documented and inadequately described clinical symptom. Because craving, like pain, is entirely subjective, no adequate external measurement has been designed that can systematically assess the psychological symptom. Craving is clinically of particular importance in certain drug abuse syndromes: cocaine abuse, abuse of the psychostimulants such as methamphetamine, and use of nicotine. The compulsion, or “driven,” quality to the craving that is described by patients habituated to these particular substances, reaches a level of intrusiveness and loss of control not seen in patients who abuse alcohol, sedative hypnotics, benzodiazepines, or opiates. By analogy of intensity and disruption, craving is to desire what panic is to anxiety. The cocaine craving sensation, in particular, can be so intense and intrusive that it disrupts concentration, interferes with performance, makes the individual acutely and extremely uncomfortable, and controls subsequent actions. In short, craving is an irresistible urge to use a substance that compels drug-seeking behavior. Patient reports suggest that cocaine craving may be stimulated by a wide range of internal cues, such as dysphoria or boredom, or by external prompts or triggers, such as cash, needles, liquor, white powder, or other environmental cues that bring to mind previous use experiences. These individual reminiscences may be so vivid and clear that they have been compared with the flashbacks experienced by LSD users in previous decades, or the flashbacks of current posttraumatic stress
From the Department of Psychiatry, Universi@ of Minnesota School of Medicine, and the Chemical Dependency Treatment Program, Universityof Minnesota Hospital and Clinic, Minneapolis MN. Address reprint requests to James A. Hal&as, M.D., Professor of Psychiatry, Universily of Minnesota, Box 393 UMHC, 420 Delaware St SE, Minneapolis, MN 55455. Copyright 0 1991 by W B. Saunders Company 0010-440X/91/3201-0002$03.00/0
22
Comprehensive
Psychiatry, Vol. 32, No. 1 (January/February),
1991: pp 22-27
23
COCAINE CRAVING SCALE
disorder patients. Protracted craving requires months to years to be attenuated and is a major factor in relapse within the first year of recovery.’ While drugs in general, and cocaine in particular, may be used by individuals for a variety of reasons other than craving, the systematic assessment of craving would assist in treatment and clinical research. At the University of Minnesota Chemical Dependency Treatment Program, over the last 2 years, we have developed and refined a cocaine craving scale that we believe to be useful, practical, and reliable when used with cocaine-using patients. This scale has been used successfully on both a daily and a weekly basis in different populations. It has met with good patient comprehension and cooperation. Dackis et al.* and others3.4 have previously described the use of a lo-cm line to measure craving for drugs from absent to maximum. After discussions with several patients about the phenomenon of craving, it was our clinical judgment that craving was more complex than could be assessed on a single dimension. Therefore, we have identified three basic dimensions to the assessment of craving in relationship to cocaine: intensity, frequency, and duration. By repeated clinical probing, it became apparent that patients are able to describe how intense the urge to use cocaine is on different occasions. This also indicated that craving as a phenomenon is episodic, that it waxes and wanes over time. This episodic quality has been previously noted.‘.’ Thus, not only could intensity be described, but also frequency per day or per week could be estimated, and time duration per episode of craving could be recollected. In this regard, craving is analogous to other subjective phenomena, in the range of human experience, such as pain, hunger, drowsiness, and sadness. Based on this information, the original scale was first expanded to three different lo-cm lines, one for each of these attributes. This instrument proved to be unreliable. Patients tended to not differentiate between the different dimensions, marking the same location for all three measurements. When discussed with them, they would acknowledge that the lo-cm lines, anchored by “none” and “a great deal” did not accurately reflect either frequency or duration, although intensity was captured by the continuous scale. The scale was therefore modified to its present format as shown in Fig 1. Frequency and duration are each aggregate estimates that can be separately judged. With this scale, each dimension of craving can be used separately to assess treatment efficacy of new treatment strategies. For example, a treatment may impact the intensity of craving, but not the frequency or duration dimensions of craving episodes. METHOD
Subjects The subjects were 35 patients enrolled in the cocaine treatment program at the University of Minnesota during 1987 to 1989. There were 23 men and 12 women. The average age of the patients was 32 years, with a range from 23 to 46. Two thirds were white (24); one third were black. These were serious drug users. Fifteen of the patients were currently on methadone maintenance; 21(60%) had a history of intravenous drug use; the patients averaged 15.6 years of lifetime drug abuse, and 7.8 years of cocaine use. They had failed in an average of 3.6 previous treatment episodes, excluding detoxification. They averaged 7.1 lifetime arrests and had been incarcerated an average of
HALIKAS ET AL
24
UNIVERSITY Department Substance
OF MINNESOTA
I H III
Study No.
Cocaine
Craving
Scale CCSl
01 Psychlalry Abuse Disorder
Program
Patient No. II
“lslt
Patlent lnltlals
m
No. /ll-
Date [IHIHI
1 On the lme below, please make a mark between “NOT AT ALL” and “A GREAT DEAL” lo w?dlcale HOW STRONG. on the average, your craving for cocaine has been DURING THE PAST WEEK INTENSITY
HOW STRONG HAS AN AVERAGE URGE BEEN:
NONE/ NOT AT ALL
I ,....I
...!
I
!..
I
1.. ,
...!
I
2 Check the box below which best indicates, on the average, HOW FREQUENTLY you have experienced craving for cxaine DURING THE PAST WEEK.
-
FREQUENCY
I
A GREAT DEAL
(how many times a day)
HOW MANY TIMES PER DAY:
00
01
q
02 11-20
[7
Morethan
3. Check the box below which best indicates, on the average, HOW LONG the craving for cocaine has lasted DURING THE PAST WEEK. DURATION cl
-HOWLONG
DOES AN AVERAGE URGE LAST (in minutes):
05 min.
cl
610mi1-1.
0
1%20min.
q
3145 min.
0
21-30min.
0
2 Hr.+
4. Overall, how has your “craving” lor cocaine changed FROM LAST WEEK?
q
lrcreased
cl
q
No clw@?
Decreased
5. How do you think your medication has affected your craving for cocaine DURING THE LAST WEEK? Sorrwvvhat Reed
GMfY Rt?dLCed
0
Fig 1. 19.3 months. These treatment.
Charge
increased
Increased
Copyright 1989. James Halikas. M.D., University of Minnesota.
The University of Minnesota Cocaine Craving Scale.
patients
reported
using cocaine
an average
of 60.7 days in the 100 days before
Cocaine Craving Scale The 35 subjects completed varying numbers of cocaine craving scales, ranging from a low of one to a high of 27. A total of 234 cocaine craving scales were completed by the 35 subjects. The time in treatment for these subjects ranged from one week to 53 weeks.
COCAINE
CRAVING
SCALE
25
RESULTS The results obtained from the cocaine craving scales suggest that craving for cocaine is of variable intensity, is typically experienced relatively few times per day, and is of short duration. The mean intensity rating for craving was 45.12 (SD 30.79). The frequency rating of craving indicated that over 90% of the time respondents reported experiencing craving no more than two times per day, with 15% of the scales (34) reporting no craving, 60% of the scales (140) reporting craving only once per day on average, and 16% (36) reporting craving on the average of twice per day. Similarly, the average duration of craving for cocaine was typically 20 minutes or less, with 44% of the scales (101) reporting an average duration of craving of 0 to 5 minutes, 21% (49) reporting craving of 6 to 10 minutes, and 20% (46) reporting craving of 11 to 20 minutes. The relationship among the three measures of cocaine craving were quite consistent, with correlations of .610 between intensity and frequency, .637 between intensity and duration, and .591 between frequency and duration. A test of validity by internal consistency among the three measurements, the extent to which they all measure the same general construct, was robust, as demonstrated by a standardized item fy of .826. Not surprisingly, craving was found to be positively related to cocaine use. The number of days of cocaine use correlated with intensity (r = .391; P < .OOl), with frequency (r = .451; P < .OOl), and with duration (r = .276; P < .OOl). Craving was also positively associated with cocaine-use dreams. Cocaine-use dreams are the phenomenon of nightmares or disturbed sleep associated with dreams of using cocaine, where the subject awakens with diaphoresis and a feeling of either having just used cocaine or of an intense need for cocaine. The number of use dreams correlated with craving intensity (r = .324; P < .OOl), with frequency (r = .312; P < .OOl), and with duration (r = .230; P < .OOl). Predicting Cocaine Abstinence
Because subjects differed greatly in the number of craving scales completed (ranging from one to 27), that portion of cocaine use variance attributable solely to the number of completed forms (46.6% of the criterion variance; F = 5.58; P < .OOl) was initially removed using dummy coding. A stepwise discriminant analysis was then performed using the remaining predictor variables to determine which, if any, were predictive of cocaine abstinence. Only one variable, cocaine craving intensity, significantly (and inversely) predicted abstinence (F = 7.91; P < .OOl): the lower the intensity of cocaine craving, the more likely the subject was able to maintain abstinence. The correlation coefficient for intensity was .332 (P < .OOl), with the single highest correlation, the canonical discriminant function coefficient, indicating that intensity contributed substantially to the discriminant classification. The final regression equation accounted for 62.7% of the total criterion variance (Wilks’ A = .367; P < .OOl). DISCUSSION
It is admittedly difficult to measure a subjective phenomenon such as craving. However, it is incumbent upon the behavioral science community to attempt to
26
HALIKAS
ET AL
develop instrumentation that can assess such subjective, intrapsychic events, retrospectively, as objectively as possible, in order to accurately assess the success of intervention efforts. We believe that this cocaine craving scale may be of assistance in this regard. It appears that cocaine craving can be separated usefully into three distinct attributes, intensity of craving, frequency of episodes of craving, and duration of each episode of craving, which can be assessed separately. This scale allows for each component of craving to be separately studied. The face validity of this scale is indicated by the correlation between craving and use on the one hand, and absence of craving and abstinence on the other. The internal validity is indicated by the similar levels of correlation among all three items. This scale may prove useful in drug treatment research. For example, the scale can provide a separate validation of efficacy for anti-craving medications as they are developed, beyond self-report of cocaine use, and current abstinence from cocaine use. Such a separate validation is necessary because compliance with any anti-craving medication regimen is likely to deteriorate if craving is not eliminated or substantially reduced.‘-” The Minnesota Craving Scale has the flexibility to be modified to meet the specific needs of those who use it. For example, intensity could be assessed for (1) worst craving episode during the past time interval, or (2) average craving episode during the past time interval. Further, separate assessment can be made of “spontaneous” craving episodes versus “prompted” craving episodes, those craving episodes triggered by external stimuli or memories. All of these appear to be components of craving. In addition, the scale as designed allows assessment of an overall patient rating, or global judgment, regarding severity of craving from one week to the next, or, when modified, from one day to the next, and allows for a global patient rating of the efficacy of any anti-craving medication being tested. This scale can be directly modified for use with any psychostimulant drug of abuse, and could, by analogy, be tried as an instrument for measurement of other subjective phenomena. We conclude that the cocaine craving scale presented in this report may be a valuable adjunct to the assessment of craving in the clinical and research setting for the study of cocaine and other psychostimulant abuse and their treatment. REFERENCES 1. Gawin FH, Ellinwood EH: Cocaine and other stimulants. N Engl .I Med 318:1173-1181,1988 2. Da&is CA, Gold MS, Sweeney DR, et al: Single-dose bromocriptine reverses cocaine craving. Psychiatry Res 20~261-264, 1987 3. Gawin FH, Kleber HD: Cocaine abuse treatment. Arch Gen Psychiatry 41:903-909,1984 4. Gold MS, Redmond DE, Kleber MD: Clonodine blocks acute opiate withdrawal symptoms. Lancet 2:599-602,1978 5. Jekel JF, Allen DF, Podlewski H, et al: Epidemic cocaine abuse: A case study from the Bahamas. Lancet 1:459-462,1976 6. Dackis CA, Gold MS: Pharmacological approaches to cocaine addiction. J Subst Abuse Treat 2:139-145,1985 7. Gawin FH, Kleber HD: Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Arch Gen Psychiatry 43:107-13, 1986 8. Halikas JA, Kemp KD, Kuhn KL, et al: Carbamazepine for cocaine addiction? Lancet 623-624, 1989 (letter)
COCAINE CRAVING SCALE
27
9. Halikas JA, Kuhn KL, Maddux TL: Reduction of cocaine use among methadone maintenance patients using concurrent carbamazepine maintenance. Ann Clin Psychiatry 2:3-6,199O 10. Halikas JA, Kemp KD, Kuhn KL, et al: Preliminary indicators of differential treatment responsiveness to carbamazepine for cocaine addiction, based on differential personality pathology. Biol Psychiatry 25:13A, 1989 (suppl, abstr) 11. Gawin FH, Kleber HD, Byck R, et al: Desipramine facilitation of initial cocaine abstinence. Arch Gen Psychiatry 46:117-121,1989
