Context In Ecological Momentary Assessment (EMA), participants electronically report their activities and moods in their daily environments in real time, enabling a truly prospective approach to the study of acute precipitants of behavioral events. EMA has greatly enhanced the study of tobacco addiction, but has rarely been attempted in individuals with cocaine or heroin addiction. Objective To prospectively monitor the acute daily-life precipitants of craving for, and use of, cocaine and heroin. Design Cohort study. Participants A volunteer sample of 114 cocaine- and heroin-abusing outpatients who were being treated with methadone provided EMA data on handheld computers for 14,918 person-days (mean 130.9 days per participant, range 6–189). Of those 114, a total of 102 (63 men, 39 women) provided acute pre-craving or pre-use data and were thus included in the present analyses. Main outcome measures Changes in reports of mood and exposure to 12 putative drug-use triggers at random intervals during the five hours preceding each self-reported episode of drug craving or use, analyzed via repeated-measures logistic regression (SAS GLIMMIX macro). Results During the five hours preceding cocaine use or heroin craving, most of the 12 putative triggers showed linear increases. Cocaine use was most robustly associated with increases in reports of “Saw Drug” (p<.0001), “Tempted to use out of the blue” (p<.0001), “Wanted to see what would happen if I used” (p<.0001), and “Good mood” (p<.0001). Heroin craving was most robustly associated with increases in reports of “Sad” (p=.0002) and “Angry” (p<.011). Cocaine craving and heroin use showed few reliable associations with any of the putative triggers assessed. Conclusions These findings confirm that polydrug-abusing individuals can provide behavioral data in their daily environments using handheld computers, and that those data can reveal orderly patterns, including prospectively detectable harbingers of craving and use, which may differ across drugs.

In addiction, risk factors for craving and use include stress and drug-related cues. Stress and cues have additive or more-than-additive effects on drug seeking in laboratory animals, but, surprisingly, seem to compete with one another (ie, exert less-than-additive effects) in human laboratory studies of craving. We sought heretofore elusive evidence that human drug users could show additive (or more-than-additive) effects of stress and cues on craving, using ecological momentary assessment (EMA). Outpatients (N=182) maintained on daily buprenorphine or methadone provided self-reports of stress, craving, mood, and behavior on electronic diaries for up to 16 weeks. In three randomly prompted entries (RPs) per day, participants reported the severity of stress and craving and whether they had seen or been offered opioids, cocaine, cannabis, methamphetamine, alcohol, or tobacco. In random-effects models controlling for between-person differences, we tested effects of momentary drug-cue exposure and stress (and their interaction) on momentary ratings of cocaine and heroin craving. For cocaine craving, the Stress × Cue interaction term had a positive mean effect across participants (M=0.019; CL95 0.001-0.036), denoting a more-than-additive effect. For heroin, the mean was not significantly greater than 0, but the confidence interval was predominantly positive (M=0.019; CL95 -0.007-0.044), suggesting at least an additive effect. Heterogeneity was substantial; qualitatively, the Stress × Cue effect appeared additive for most participants, more than additive for a sizeable minority, and competitive in very few. In the field, unlike in human laboratory studies to date, craving for cocaine and heroin is greater with the combination of drug cues and stress than with either alone. For a substantial minority of users, the combined effect may be more than additive.

Stress increased before stressful-event entries, but was less evident before drug use. Craving increased in the hours before drug use and stressful events-and remained elevated in the hours after either event. These results suggest a stronger link between drug use and craving than between drug use and stress. Lapses to drug use did not improve mood or reduce stress, at least not at our 1-h-bin time resolution, suggesting that if such benefits exist, they are brief.

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Background: Responses to stress and drug craving differ between men and women. Differences in the momentary experience of stress in relation to craving are less well-understood. Objectives: Using ecological momentary assessment (EMA), we examined sex differences in real-time in two areas: 1) causes and contexts associated with stress, and 2) the extent to which stress and drug cues are associated with craving. Methods: Outpatients on opioid-agonist treatment (135 males, 47 females) reported stress, craving, and behavior on smartphones for 16 weeks. They initiated an entry each time they felt more stressed than usual (stress event) and made randomly prompted entries 3 times/day. In stress-event entries, they identified the causes and context (location, activity, companions), and rated stress and craving severity. Results: The causes reported for stress events did not differ significantly by sex. Women reported arguing and being in a store more often during stress events, and men reported working more often during stress events, compared to base rates (assessed via random prompts). Women showed a greater increase in opioid craving as a function of stress (p<0.0001), and had higher stress ratings in the presence of both stress and drug cues relative to men (p<0.01). Similar effects were found for cocaine craving in men (p<0.0001). Conclusion: EMA methods provide evidence based on real-time activities and moods that opioid-dependent men and women experience similar contexts and causes for stress but differ in stress- and cue-induced craving. Assessment of both sex and person-level differences may help to develop better tailored treatments.