Effectiveness and Utility of Mobile Device Assessment of Subjective Craving during Residential Opioid Dependence Treatment

Predictors of substance use during treatment for addiction: A network analysis of ecological momentary assessment data

BACKGROUND AND AIMS

Ecological momentary assessment (EMA) studies have previously demonstrated a prospective influence of craving on substance use in the following hours. Conceptualizing substance use as a dynamic system of causal elements could provide valuable insights into the interaction of craving with other symptoms in the process of relapse. The aim of this study was to improve the understanding of these daily life dynamic inter-relationships by applying dynamic networks analyses to EMA data sets.

DESIGN, SETTING AND PARTICIPANTS

Secondary analyses were conducted on time-series data from two 2-week EMA studies. Data were collected in French outpatient addiction treatment centres. A total of 211 outpatients beginning treatment for alcohol, tobacco, cannabis, stimulants and opiate addiction took part.

MEASUREMENTS

Using mobile technologies, participants were questioned four times per day relative to substance use, craving, exposure to cues, mood, self-efficacy and pharmacological addiction treatment use. Multi-level vector auto-regression models were used to explore contemporaneous, temporal and between-subjects networks.

FINDINGS

Among the 8260 daily evaluations, the temporal network model, which depicts the lagged associations of symptoms within participants, demonstrated a unidirectional association between craving intensity at one time (T0) and primary substance use at the next assessment (T1, r = 0.1), after controlling for the effect of all other variables. A greater self-efficacy at T0 was associated with fewer cues (r = -0.04), less craving (r = -0.1) and less substance use at T1 (r = -0.07), and craving presented a negative feedback loop with self-efficacy (r = -0.09).

CONCLUSIONS

Dynamic network analyses showed that, among outpatients beginning treatment for addiction, high craving, together with low self-efficacy, appear to predict substance use more strongly than low mood or high exposure to cues.

Ecological momentary assessment and cue-elicited drug craving as primary endpoints: study protocol for a randomized, double-blind, placebo-controlled clinical trial testing the efficacy of a GLP-1 receptor agonist in opioid use disorder

BACKGROUND

Despite continuing advancements in treatments for opioid use disorder (OUD), continued high rates of relapse indicate the need for more effective approaches, including novel pharmacological interventions. Glucagon-like peptide 1 receptor agonists (GLP-1RA) provide a promising avenue as a non-opioid medication for the treatment of OUD. Whereas GLP-1RAs have shown promise as a treatment for alcohol and nicotine use disorders, to date, no controlled clinical trials have been conducted to determine if a GLP-1RA can reduce craving in individuals with OUD. The purpose of the current protocol was to evaluate the potential for a GLP-1RA, liraglutide, to safely and effectively reduce craving in an OUD population in residential treatment.

METHOD

This preliminary study was a randomized, double-blinded, placebo-controlled clinical trial designed to test the safety and efficacy of the GLP-1RA, liraglutide, in 40 participants in residential treatment for OUD. Along with taking a range of safety measures, efficacy for cue-induced craving was evaluated prior to (Day 1) and following (Day 19) treatment using a Visual Analogue Scale (VAS) in response to a cue reactivity task during functional near-infrared spectroscopy (fNIRS) and for craving. Efficacy of treatment for ambient craving was assessed using Ecological Momentary Assessment (EMA) prior to (Study Day 1), across (Study Days 2-19), and following (Study Days 20-21) residential treatment.

DISCUSSION

This manuscript describes a protocol to collect clinical data on the safety and efficacy of a GLP-1RA, liraglutide, during residential treatment of persons with OUD, laying the groundwork for further evaluation in a larger, outpatient OUD population. Improved understanding of innovative, non-opioid based treatments for OUD will have the potential to inform community-based interventions and health policy, assist physicians and health care professionals in the treatment of persons with OUD, and to support individuals with OUD in their effort to live a healthy life.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04199728. Registered 16 December 2019, https://clinicaltrials.gov/study/NCT04199728?term=NCT04199728 .

PROTOCOL VERSION

10 May 2023.

Craving dynamics and related cerebral substrates predict timing of use in alcohol, tobacco, and cannabis use disorders

Background

Patients treated for Substance Use Disorders exhibit highly fluctuating patterns of craving that could reveal novel prognostic markers of use. Accordingly, we 1) measured fluctuations within intensively repeated measures of craving and 2) linked fluctuations of craving to connectivity indices within resting-state (rs) brain regions to assess their relation to use among patients undergoing treatment for Alcohol, Tobacco and Cannabis Use Disorders.

Method

Participants -64 individuals with SUD for tobacco, alcohol, or cannabis and 35 healthy controls-completed a week of Ecological Momentary Assessment (EMA) during which they reported craving intensity and substance use five times daily. Before EMA, a subsample of 50 patients, and 34 healthy controls also completed resting-state (rs)-MRI acquisitions. Craving temporal dynamics within each day were characterized using Standard Deviation (SD), Auto-Correlation Factor (ACF), and Mean Successive Square Difference (MSSD). Absolute Difference (AD) in craving between assessments was a prospective prediction measure.

Results

Within-day, higher MSSD predicted greater substance use while controlling for mean craving. Prospectively higher AD predicted later increased substance use independently of previous use or craving level. Moreover, MSSD was linked to strength in five functional neural connections, most involving frontotemporal systems. Cerebello-thalamic and thalamo-frontal connectivity were also linked to substance use and distinguished the SUD from the controls.

Conclusion

To the best of our knowledge, this is the first study to indicate that instability in craving may be a trigger for use in several SUD types, beyond the known effect of craving intensity.

Momentary Craving, Craving Variability, and Cannabis Use: Associations With THC Concentrates and Sex

OBJECTIVE

Ecological momentary assessment (EMA) studies are well positioned to assess the impact of craving on cannabis use in real time and may better capture its time-varying nature. The goal of this exploratory study was to examine whether momentary craving and craving variability predict subsequent use of cannabis and how baseline concentrate use status and male sex might affect these relationships.

METHOD

College students residing in a state with legal recreational cannabis use who used cannabis twice a week or more completed a baseline interview and signal-contingent EMA for 2 weeks using a smartphone application. Hierarchical (multi-level) regression was used to examine time-lagged associations between craving, craving variability, and subsequent cannabis use. Baseline concentrate use and male sex were examined as moderators.

RESULTS

Participants (N = 109) included 59% women, with an average age of 20.2 years, and most using cannabis near-daily or daily. A main effect for craving (within-level effect) on the likelihood of cannabis use at the next EMA instance was found (odds ratio = 1.292, p < .001), although this effect was moderated by concentrate use status. For men, between-level increases in craving led to a greater likelihood of cannabis use at the next instance, but greater craving variability led to a lower likelihood of use. Greater variability in craving was associated with a greater likelihood of cannabis use among those using concentrates.

CONCLUSIONS

The experience of craving may differ based on important participant characteristics. More research examining the fluctuating nature of craving and the role of cannabis potency on craving is warranted.

The centrality of craving in network analysis of five substance use disorders

BACKGROUND AND AIMS

Among the 11 current diagnostic criteria, craving is a potential central marker for understanding and for treatment of Substance Use Disorders (SUD). Our objective was to explore craving centrality across SUD based on the study of symptom interactions in cross-sectional network analyses of DSM-5 SUD diagnostic criteria. We hypothesized the centrality of "Craving" in SUD across substance types.

DESIGN

Participants from the ADDICTAQUI clinical cohort with regular use (2 times per week threshold for a substance) and at least one DSM-5 SUD.

SETTING

Outpatient substance use treatment services in Bordeaux, France.

PARTICIPANTS

The sample of 1359 participants, had a mean age of 39 years old and 67% were males. The prevalence of SUD over the time course of the study was: 93% for alcohol, 98% for opioids, 94% for cocaine, 94% for cannabis and 91% tobacco.

MEASUREMENTS

Construction of a Symptom Network Model conducted on the DSM-5 SUD criteria evaluated over the past 12 months for Alcohol-, Cocaine-, Tobacco-, Opioid- and Cannabis Use disorder.

FINDINGS

The only symptom that consistently remained in terms of centrality was "Craving" [3.96 - 6.17] (z-scores), indicating that it exhibits a high degree of connections in the entire symptom network regardless of the substance.

CONCLUSION

Identifying craving as central in SUD symptoms network confirms the role of craving as a marker of addiction. This constitutes a major avenue in the understanding of the mechanisms of addiction, with implications to ameliorate diagnostic validity and clarify treatment targets.

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Using ecological momentary assessments of negative affect and craving during residential opioid use disorder treatment to predict patients' relapse to substance use

BACKGROUND

Negative affect (NA) and craving are often independently examined as precipitators of relapse among individuals with substance use disorders, including opioid use disorder (OUD). Recent ecological momentary assessment (EMA) research has revealed that NA and craving frequently co-occur within individuals. Yet we know little about the general patterns of, and variability in, within-person associations between NA and craving, as well as whether the nature and degree of within-person NA-craving coupling predicts post-treatment time-to-relapse.

METHODS

Seventy-three patients (77 % male, Mage = 30.10, Range = 19-61) in residential treatment for OUD took part in a 12-day, 4× daily smartphone-based EMA study. Linear mixed-effects models tested within-person, day-level associations between self-reported NA and craving during treatment. The study used Person-specific slopes (i.e., average within-person NA-craving coupling for each participant) estimated from the mixed-effects model in survival analyses with Cox proportional hazards regression models to determine if between-person differences in the within-person coupling predicted post-treatment time-to-relapse (operationalized as the return to problematic use of any substance except tobacco), and whether this prediction was similar across patients' average levels of NA and craving intensity. The study monitored relapse through a combination of hair samples and reports from patients or alternative contacts via a voice response system twice a month for up to 120 days or more following discharge.

RESULTS

Among the 61 participants with time-to-relapse data, those with stronger positive within-person NA-craving coupling on average during residential OUD treatment had a lower hazard of relapsing (slower time to relapse) post-treatment than participants with weaker NA-craving slopes. The significant association held after controlling for interindividual differences in age, sex, and average levels of NA and craving intensity. Average NA and craving intensity did not moderate the association between NA-craving coupling and time-to-relapse.

CONCLUSIONS

Interindividual differences in average within-person, day-level NA-craving coupling during residential treatment predict OUD patients' post-treatment time-to-relapse.

Prefrontal cortical response to natural rewards and self-reported anhedonia are associated with greater craving among recently withdrawn patients in residential treatment for opioid use disorder

Both anhedonia and craving are common among patients with opioid use disorder (OUD), and are associated with vulnerability to relapse. Although these constructs are theoretically linked relatively few studies have examined them together. In the current study, recently withdrawn patients (N = 71) in residential treatment for prescription OUD underwent a cue reactivity paradigm while being monitored with functional near-infrared spectroscopy (fNIRS). Patients also self-reported symptoms of anhedonia via the Snaith-Hamilton Pleasure Scale (SHAPS), while smartphone-based ecological momentary assessments (EMA) were used to measure craving levels. On average, lower right prefrontal cortex (PFC) activity in response to positive social stimuli was associated with higher craving (β = - 2.87; S.E. = 1.23; p = 0.02). Self-reported anhedonia moderated the association between PFC activity and craving (β = - 1.02; S.E. = 0.48; p = 0.04), such that patients with two or more anhedonic symptoms had a significant and stronger negative association between PFC activation to hedonically positive images and craving, compared to patients with fewer than two anhedonic symptoms, among whom the association was not significant. This finding provides evidence that higher levels of anhedonia among patients in residential treatment for OUD are associated with a stronger link between lower PFC response to positive social experiences and higher levels of craving, potentially increasing overall vulnerability to relapse.

Intra-individual variability and stability of affect and craving among individuals receiving medication treatment for opioid use disorder

Affect and craving are dynamic processes that are clinically relevant in opioid use disorder (OUD) treatment, and can be quantified in terms of intra-individual variability and stability. The purpose of the present analysis was to explore associations between opioid use and variability and stability of affect and craving among individuals receiving medication treatment for OUD (MOUD). Adults (N = 224) with OUD in outpatient methadone or buprenorphine treatment completed ecological momentary assessment (EMA) prompts assessing positive affect, negative affect, opioid craving, and opioid use. Dynamic structural equation modeling (DSEM) was used to quantify person-level indices of magnitude and stability of change. Beta regression was used to examine associations between intra-individual variability and stability and proportion of opioid-use days, when controlling for overall intensity of affect and craving. Results suggested that greater magnitude of craving variability was associated with opioid use on a greater proportion of days, particularly among individuals with lower average craving. Low average positive affect was also associated with higher proportion of days of use. Individuals who experience substantial craving variability in the context of lower average craving may be particularly vulnerable to opioid use during treatment. Ongoing assessment of craving may be useful in identifying treatment needs. Examining correlates of intra-individual variability and stability in MOUD treatment remains a relevant direction for future work.

The 24-hour rhythm in alcohol craving and individual differences in sleep characteristics and alcohol use frequency

BACKGROUND

Evidence implicates sleep/circadian factors in alcohol use, suggesting the existence of a 24-h rhythm in alcohol craving, which may vary by individual differences in sleep factors and alcohol use frequency. This study sought to (1) replicate prior findings of a 24-h rhythm in alcohol craving, and (2) examine whether individual differences in sleep timing, sleep duration, or alcohol use frequency are related to differences in the timing of the peak of the craving rhythm (i.e., the acrophase) or magnitude of fluctuation of the rhythm (i.e., amplitude). Finally, whether such associations varied by sex or racial identity was explored.

METHODS

Two-hundred fifteen adult drinkers (21 to 35 years of age, 72% male, 66% self-identified as White) completed a baseline assessment of alcohol use frequency and then smartphone reports of alcohol craving intensity six times a day across 10 days. Sleep timing was also recorded each morning of the 10-day period. Multilevel cosinor analysis was used to test the presence of a 24-h rhythm and to estimate acrophase and amplitude.

RESULTS

Multilevel cosinor analysis revealed a 24-h rhythm in alcohol craving. Individual differences in sleep timing or sleep duration did not predict rhythm acrophase or amplitude. However, alcohol use frequency moderated this rhythm wherein individuals who used alcohol more frequently in the 30 days prior to beginning the study had higher mean levels of craving and greater rhythm amplitudes (i.e., greater rhythmic fluctuations). Associations did not vary by sex or racial identity.

CONCLUSIONS

Results show that alcohol craving exhibits a systematic rhythm over the course of the 24 h and that the frequency of alcohol use may be relevant to the shape of this rhythm. Consideration of daily rhythms in alcohol craving may further our understanding of the mechanisms that drive alcohol use.

Effects of arousal modulation via resonance breathing on craving and affect in women with substance use disorder

BACKGROUND

Craving for alcohol and other drugs is a complex in-the-moment experience that involves within-person changes in physiological arousal and affect. We evaluated the utility of a just-in-time, self-administered resonance breathing smartphone application (app) to reduce craving and improve affect in women during outpatient treatment for substance use disorders (SUD).

METHODS

Women (N = 57) receiving outpatient addiction treatment were randomized to practice either cardiovascular resonance breathing (0.1 Hz/6 breaths per minute) or a sham (∼0.23 Hz/14 breaths per minute) in the face of urges over an 8-week intervention. Craving (Penn Alcohol Craving Scale) and affect (Positive and Negative Affect Scale) were collected weekly throughout the intervention. App data were uploaded weekly to assess frequency of use. Generalized Estimated Equations modeled craving and affect as a function of group randomization and app use frequency across the 8-week intervention.

FINDINGS

Higher levels of craving were associated with more frequent app use. The group X app use interaction was significant for craving. Frequent app use during the intervention phase was associated with lower craving levels in the resonance breathing group relative to the sham group over the 8-week intervention. There was no effect of app use frequency on affect measures.

CONCLUSIONS

Women assigned to practice sham breathing who used the intervention frequently experienced elevations in craving that are commonly reported during outpatient SUD treatment. Women assigned to resonance breathing who used the intervention frequently did not experience such increases. Resonance breathing may be protective against triggers in outpatient treatment. Physiological mechanisms are discussed.