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.

Rationale-Craving is often assumed to cause ongoing drug use and relapse and is a major focus of addiction research. However, its relationship to drug use has not been adequately documented.Objectives-The aim of this study was to investigate the relationship between craving and drug use in real time and in the daily living environments of drug users. Methods-In a prospective, longitudinal, cohort design (Ecological Momentary Assessment), 112cocaine-abusing individuals in methadone maintenance treatment rated their craving and mood at random times (two to five times daily, prompted by electronic diaries) as they went about their everyday activities. They also initiated an electronic-diary entry each time they used cocaine. Drug use was monitored by thrice-weekly urine testing.Results-During periods of urine-verified cocaine use, ratings of cocaine craving increased across the day and were higher than during periods of urine-verified abstinence. During the five hours prior to cocaine use, ratings of craving significantly increased. These patterns were not seen in ratings of heroin craving or mood (e.g., feeling happy or bored).Conclusions-Cocaine craving is tightly coupled to cocaine use in users' normal environments. Our findings provide previously unavailable support for a relationship that has been seriously questioned in some theoretical accounts. We discuss what steps will be needed to determine whether craving causes use. Keywordscraving; Ecological Momentary Assessment; cocaine; mood; addiction; psychological theory Craving-a conscious, reportable urge-is a frequently discussed aspect of drug addiction (Lowman et al. 2000;Pickens and Johanson 1992), but its exact role in addiction, particularly its relationship with drug use and relapse, has been disputed from both theoretical and clinical perspectives. Across the spectrum of addiction theories, craving is given varying degrees of importance as a driver of drug use (Drummond 2001). NIH Public AccessAuthor Manuscript Psychopharmacology (Berl). Author manuscript; available in PMC 2010 September 20. Published in final edited form as:Psychopharmacology (Berl Clinical studies of the relationship between craving and drug use have had mixed results. Some studies have shown that craving before or during treatment predicts post-treatment cocaine use (Baer et al. 1989;Hartz et al. 2001;Paliwal et al. 2008;Rohsenow et al. 2007;Weiss et al. 2003), while others have shown no relationship (Kranzler et al. 1999;Walton et al. 2003;Weiss et al. 1995). In laboratory studies, the amount of cocaine craving induced by stressors in experimental sessions predicts time to resumption of cocaine use in daily life ; similar findings have been reported for tobacco smokers, with either stress-induced (al'Absi et al. 2005) or cue-induced craving . However, during an experimental session, reductions in craving do not necessarily lead to reductions in drug selfadministration (Haney and Spealman 2008;Leyton et al. 2005;Sofuoglu et al. 2009).In spite of the mixed clinical data, muc...

Background Maladaptive behaviors may be more fully understood and efficiently prevented by ambulatory tools that assess people’s ongoing experience in the context of their environment. Methods To demonstrate new field-deployable methods for assessing mood and behavior as a function of neighborhood surroundings (Geographical Momentary Assessment; GMA), we collected time-stamped GPS data and Ecological Momentary Assessment (EMA) ratings of mood, stress, and drug craving over 16 weeks at randomly prompted times during the waking hours of opioid-dependent polydrug users receiving methadone maintenance. Locations of EMA entries and participants’ travel tracks were calculated for the 12 hours before each EMA entry were mapped. Associations between subjective ratings and objective environmental ratings were evaluated at the whole neighborhood and 12-hour track levels. Results Participants (N=27) were compliant with GMA data collection; 3,711 randomly prompted EMA entries were matched to specific locations. At the neighborhood level, physical disorder was negatively correlated with negative mood, stress, and heroin and cocaine craving (ps <.0001 to .0335); drug activity was negatively correlated with stress, heroin and cocaine craving (ps .0009 to .0134). Similar relationships were found for the environments around respondents’ tracks in the 12 hours preceding EMA entries. Conclusions The results support the feasibility of GMA. The relationships between neighborhood characteristics and participants’ reports were counterintuitive and counter-hypothesized, and challenge some assumptions about how ostensibly stressful environments are associated with lived experience and how such environments ultimately impair health. GMA methodology may have applications for development of individual- or neighborhood-level interventions.

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.