In this article, by reviewing the psychological, psychophysiological, neurobiological, and psychopharmacological literature on craving for alcohol, it is argued that converging evidence from several disciplines suggests a three-pathway psychobiological model of craving. Essential to this model is the appreciation of the role of individual differences in affect regulation strategies or personality styles, conditionability, sensitivity to alcohol's effects, and related dysregulations in distinct neural circuitries or neurotransmitter systems. These factors are of crucial importance to a proper understanding of the nature of craving, its underlying mechanisms and different manifestations. As a first pathway, it is suggested that reward craving or desire for the rewarding, stimulating and/or enhancing effects of alcohol might result from either dopaminergic/opioidergic dysregulation or a personality style characterized by reward seeking or a combination of both. As a second pathway, it is suggested that relief craving or desire for the reduction of tension or arousal might result from either gamma-aminobutyric acid (GABA)ergic/glutamatergic dysregulation or a personality style characterized by stress reactivity or a combination of both. Obsessive craving, the result of the third pathway, can be defined as lack of control over intrusive thoughts about drinking resulting in impaired functioning. This type of craving might result either from a serotonin deficiency or a personality style characterized by low constraint or disinhibition or a combination of both. The putative implications of this three-pathway model for the assessment of alcohol craving, diagnosis and treatment of alcoholism, and future research on craving, are discussed.

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This paper attempts to summarize the measurement of craving with four different craving instruments and to relate this to definitions and measurement of relapse. The definitions of relapse may vary between studies and researchers, but are usually well defined. Five commonly used methods to measure relapse are: (1) quantity/frequency of drinking; (2) cumulative duration of abstinence (CDA); (3) post-withdrawal abstinent period; (4) stable recovery period; (5) the time line follow-back method. The definition of craving is much less clear and is mostly described as an emotional-motivational state or as obsessive-compulsive behaviour. Four self-rating instruments are briefly discussed and compared: the Obsessive-Compulsive Drinking Scale, OCDS, the Lübeck Craving Scale, LCRR, the Alcohol Craving Questionnaire, ACQ-Now-SF-R, and ordinal scales (e.g. visual analogue, Likert, or verbal descriptive scales). These instruments measure different aspects or dimensions of craving over different periods. The different dimensions measured suggest that there is still a need to conceptualize a standard interpretation of the word craving. There is a need also to measure an emotional-motivational dimension, a cognitive-behavioural dimension, expectancies, and effects on positive and negative reinforcement with different instruments or with one multidimensional instrument. It is suggested that different patients are expected to have different craving profiles.

The most straight-forward clinical implication of this study is that acamprosate can be considered as a potentially effective pharmacotherapy for all patients with alcohol dependence. The effect size of acamprosate alone is, however, moderate. Some evidence indicates that the combination of acamprosate with naltrexone or disulfiram leads to substantially better outcomes.