Instructions attached with the class readings and resources. This document is copyrighted by the American

Instructions attached with the class readings and resources.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
A Wiley Periodicals, Inc. publication. wileyonlinelibrary.comWAWhen CommonWealth Magazine ran an article by Andrew Klein, Ph.D., on Jan. 4, our first question was “Why?” The main reason was to push back against an increasing demand for prisons and jails to offer agonists, Klein said. Despite the plethora of research showing ago-nists are effective treatment for opi-oid use disorder (OUD), including for incarcerated patients, Klein, a researcher, deviates from the main-stream of peer-reviewed literature and seems to side more with the criminal justice system. So we talked to both Klein and a physician in charge of a jail-based treatment sys-tem for this story.The article, titled “Four reasons medication-assisted treatment may not help inmates,” with the subhead Addiction consult services in hospitals show promise in facilitating ongoing careBottom Line…Some hospitals are making inroads in identifying patients who can benefit from referral to community-based care for addictions, but a study concludes that the structure of many of the medical consulting arrangements could be improved.“It’s not clear providing opioid med-ications to prisoners is always the best course” (Klein says the publica-tion, not him, bears the responsibil-ity for the headline), opens with a description of a federal district court decision requiring an Essex County, Massachusetts, jail to provide metha-done to an inmate, who had been taking the medication successfully for two years (see ADAW, Dec. 3, 2018). The jail operates a See Jails page 2Addiction medicine consulting teams in acute-care hospitals are beginning to show promise as an effective refer-ral source to specialty treatment for opioid use disorders (OUDs). But inconsistencies in how these consult services are structured suggests much room for refinement, according to a newly published study.One of the critical gaps to this point is a lack of peer representation on many consulting teams, with a peer in place at only one of the nine addiction medicine consult (AMC) services that were examined as part of the latest research. Moreover, even at that one location with peer involve-ment, implementation challenges arose over issues such as the peer’s status as an unlicensed worker.“Hospital staff unaffiliated with the AMC service were not used to having ‘fierce advocates’ at the bed-side,” wrote study co-authors Kelsey Priest and Dennis McCarty, Ph.D., of Oregon Health & Science University (Priest is a fifth-year M.D./Ph.D. See Consults page 6Bias against agonist treatment for incarcerated people continuesBottom Line…Despite repeated data showing treating incarcerated people who have opioid use disorder with agonists results in reduced overdoses and deaths after release, bias persists.
6Consults from page 1Tracey Helton has been running peer programs for a decade, and involved with harm-reduction work for two. Her “real” day job is work-ing for San Francisco, a job that includes benefits and enables her to support her children. But it also allows her to run harm-reduction services “from my closet,” as she puts it. We called her because we wanted to learn more about how she views the field.And Helton is a bit concerned about some of the trends she has seen. “Because of the huge increases in overdoses, there’s a new genera-tion of people getting into harm-reduction work, work that has expanded out beyond traditional public health,” Helton told ADAW last week. “People get involved in this work because they believe in the cause, but a lot are not ade-quately prepared for the mental and physical health implications of the work,” she said.Many of these workers are vol-unteers. Some are themselves cur-rent drug users. But what are the support systems for these workers, who see tragedy and near-tragedy on a daily basis? “In the Bay Area, when you’re doing outreach, you’re reviving people from overdoses, you’re calling ambulances,” said Helton. “These things can be very traumatic. What are the safeguards for these people?”For starters, it would help for staff to be paid, said Helton. “But if it’s up to the individual agency that’s bringing in volunteers, there are still things you can do,” she said. “We have unprecedented levels of death now. We need to have debriefs of critical incidents, retreats for people to get together and unwind from some of these events.”There are also online support groups, as well as training through the Harm Reduction Coalition, which has regional and national conferences and provides profes-sional development, said Helton. It’s also important to “mingle with peo-ple in the same field,” she said.But the bottom line is some-thing that will resonate with people who work in the addiction recovery movement: taking care of yourself. “Self-care is a radical act,” said Hel-ton. “We have to make harm reduc-tion safe and inclusive, so we can draw in other communities.”For herself, Helton, who has been a methadone patient and who worked in a methadone clinic for five years, said support groups are critical. “I belong to two different Facebook groups for people who are on methadone,” she said. “You see increasing numbers of people advocating for the needs of people on methadone, for changing federal regulations, for getting rid of the stigma,” she said.Meanwhile, Helton’s job is her self-care. She has a good salary and benefits. This enables her to do the grassroots work she does as a city employee. She’s not inter-ested in going back into the sub-stance use disorder workforce, where the pay is very low. Instead, she’ll continue to do her harm-reduction work for free. •New generation of harm-reduction workers: Helton’s concernsstudent in the university’s School of Public Health, and McCarty is a uni-versity professor and a former state substance abuse director in Massachusetts).With most hospital systems not addressing OUD-specific treatment and discharge planning needs within their populations, “The AMC services are an important advance in quality of care for persons with alcohol and drug use disorders, especially opioid use disorders,” McCarty told ADAW.Study findingsPublished online Dec. 28 in the American Society of Addiction Medi-cine’s Journal of Addiction Medi-cine, the study involved data collection via telephone interviews with board-certified addiction medi-cine physicians affiliated with the Addiction Medicine Foundation’s Addiction Medicine Fellowship Pro-grams. The represented hospitals were scattered across the country, with most located in Medicaid expansion states and all having access to buprenorphine and metha-done treatment among the services available to OUD patients.Here are some of the key findings gleaned from the interviews with the professionals, whom the researchers referred to as “informants”:• Only one of the nine AMC ser-vices that were represented in the study offered in-person consults over the weekend, so these were largely weekday-only services. “The informants, in general, were frustrated with the limited AMC service avail-ability because patients admit-ted or discharged over the weekend were not receiving life-saving addiction-related ser-vices,” the researchers wrote.• Three of the nine AMC servic-es provided consultations in the hospital’s emergency de-partment. This was another component that informants in-creasingly considered to be an essential component of pro-gram design.• The consulting teams generally consisted of a diverse mix of professionals. Physician repre-sentation was present on each, while four of the nine services included social workers and only two of the nine included alcohol and drug counselors.• The common core services of-fered by the teams were sub-stance use disorder and mental health assessments, psycholog-ical intervention, medical man-agement of substance use dis-orders, medical management
7A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.comworking with nine hospitals to furnish round-the-clock access to a specialist (including on week-ends) to meet with patients in emergency or hospital detox set-tings, in order to plan the transi-tion to outpatient care.Tom Britton said State Targeted Response to the Opioid Crisis mon-ies have supported this effort, but he sees formalized partnerships between hospitals and community providers as a major business oppor-tunity for the specialty treatment sector — given the high costs that hospitals bear even for very short-term treatment of patients with addictions. “We sell this service to hospitals,” he said.Britton explained that patients in the hospitals with which Gateway works (located in a diversity of urban, suburban and rural commu-nities) may be seen by either a clini-cian or a peer, under the supervision of an addiction medicine specialist. “We have been successful in build-ing a network of [community] place-ment options to meet the needs of a 24/7 model,” he said.Around 20 percent of Gateway’s typical patient base receives medica-tion-assisted treatment, and Britton suspects that with the level of acuity high in the hospitalized population for which it is consulting, a good number of those individuals will be on medication when they are placed in community treatment.Over the past year and a half, Gateway has seen 1,000 hospitalized patients in this capacity, Britton said. The placement rate for these indi-viduals has been 90 percent, but only about 10 percent of that 90 per-cent have been referred to Gate-way’s own programs. That speaks to the larger communitywide goal of this initiative, a factor Britton says could pose a challenge for some treatment programs.“You have to do what’s best for the patient and what’s best for the hospital,” Britton said, and that is not necessarily always what’s best for one’s own program. •of pain and linkage to care. The latter encompasses both referral to treatment and “bridge” services such as a pre-scription for buprenorphine to serve the patient until he/she has established care from a provider in the community.• The service plays a broad ed-ucational role for the rest of the hospital staff in highlight-ing that addictions need to be treated in a medical context. One informant said in the in-terview that “it just raises the profile of addiction in general when there is a consult ser-vice identified with it.”• The surveyed services gener-ally struggled with acquiring the financial resources for op-erations, with most surviving on a patchwork of govern-ment, insurance and private funding. The analysis suggests that the Centers for Medicare & Medicaid Services could make a difference in this re-gard, by increasing reimburse-ment for hospital-based addic-tion treatment services.New York City’s effortThe study paper states that most of the existing AMCs were recently established. One of the efforts that was not part of this study but should generate significant research find-ings in the future is taking place in New York City, which has plans in the works for a total of six Consult for Addiction Treatment and Care in Hospitals (CATCH) teams in areas hit hardest by the opioid epidemic.Leaders with the NYC Health + Hospitals agency told MHW that while these services are intended to address all addictions, OUD services will be the present focus given the magnitude of the opioid crisis. The effort is being funded in part with monies from the comprehensive Healing NYC initiative out of the New York City mayor’s office, with additional funding sup-port from a National Institute on Drug Abuse grant.Lynsey Avalone, associate direc-tor of NYC Health + Hospitals’ Office of Behavioral Health, said each of the consulting teams will include a pre-scriber (either a physician or a nurse practitioner), a counselor/social worker and a certified peer recovery advocate. The city has a more exten-sive history with integrating peer ser-vices (such as in mental health care) than many communities, and there are plans also to house peers in city hospital emergency rooms as part of a separate initiative.Avalone said that at the inpa-tient level, the CATCH team’s efforts could range from a simple recom-mendation for a hospital staff physi-cian on a medication treatment for addiction to assisting in care right through discharge from the hospital. The programs in New York City also include bridge clinic services for patients who might not have a pro-vider for medication-assisted treat-ment immediately upon discharge. Avalone said bridge clinic services will operate in a fashion similar to an outpatient primary care clinic.Two of the planned CATCH team sites, at NYC Health + Hospi-tals/Bellevue and Lincoln, went into full operation in the second half of 2018, with another two of the six planned sites already fully staffed.With MAT and other treatment capacity at a higher level in New York City than in some communities, the consult services can help facili-tate rapid referral to ongoing treat-ment for hospitalized patients with OUD, according to city leaders.Study co-author Priest told ADAW that in a forthcoming paper, the researchers will describe how the level of availability of commu-nity-based services facilitates or deters the existence of AMC ser-vices. “The connection with commu-nity treatment services is critical,” Priest said.Efforts in Illinois hospitalsThe CEO of Chicago-based Gateway Foundation told ADAW that his treatment organization is
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ArticleUseofCausalLanguageinStudiesontheRelationshipbetweenSpiritually-BasedTreatmentsandSubstanceAbuseandRelapsePreventionIvánSánchez-Iglesias1,MartaGonzález-Castaño2andAntonioJ.Molina2,*Citation:Sánchez-Iglesias,Iván,MartaGonzález-Castaño,andAntonioJ.Molina.2021.UseofCausalLanguageinStudiesontheRelationshipbetweenSpiritually-BasedTreatmentsandSubstanceAbuseandRelapsePrevention.Religions12:1075.https://doi.org/10.3390/rel12121075AcademicEditor:ChristianZwingmannReceived:11November2021Accepted:30November2021Published:3December2021Publisher’sNote:MDPIstaysneutralwithregardtojurisdictionalclaimsinpublishedmapsandinstitutionalafﬁl-iations.Copyright:©2021bytheauthors.LicenseeMDPI,Basel,Switzerland.ThisarticleisanopenaccessarticledistributedunderthetermsandconditionsoftheCreativeCommonsAttribution(CCBY)license(https://creativecommons.org/licenses/by/4.0/).1Psychobiology&BehavioralSciencesMethods,ComplutenseUniversityofMadrid,28040Madrid,Spain;i.sanchez@psi.ucm.es2Social,WorkandDifferentialPsychology,ComplutenseUniversityofMadrid,28040Madrid,Spain;martagc@ucm.es*Correspondence:antmolin@ucm.esAbstract:Themaingoalofscientiﬁcresearchistoexplainwhatcausesaphenomenon.However,onlywell-controlledstudiesguaranteesufﬁcientinternalvaliditytosupportcausalexplanations(i.e.,experimentalandsomequasi-experimentaldesigns).Theuseofcausalclaimsinnon-experimentalstudiescanmisleadreadersintoassumingacause–effectrelationshipwhenalternativeexplanationshavenotbeenruledout,underminingtheprincipleofscientiﬁcrigorandthecredibilityofscientiﬁcﬁndings.Althoughspiritualpracticesformpartofsomeinterventionsforhealthandbehavioralproblems,theireffectivenesscannotoftenbeassessedviaexperimentalmethodology.Thispaperassessesthevalidityofcausalinferencesinpublishednon-experimentalstudies,andmorespeciﬁcallyinstudiesontherelationshipbetweenspirituallybasedtreatmentsandsubstanceabuseimprovementandrelapseprevention.WeconductedasystematicreviewusingScopus,Pubmed,andseveraldatabasesincludedinProQuest,fortheperiod2015to2020.Outof16studiesselected,sixstudies(37.5%)usedcorrectlanguageinthetitle,abstract,anddiscussionsections;10studies(68.8%)usedtendentiousorincorrectlanguageinatleastonesection.Spirituallybasedtreatmentsshowpromisingresultsinsomehealthimprovementoutcomes.Moststudiesshowtransparencywhenreportingresults.However,researchersshouldbecarefulnottomakecausalassertionsunlesstheinternalvalidityoftheresearchissound.Keywords:casuallanguage;scientiﬁcwriting;causality;spirituallybasedtreatment;substanceabuse1.IntroductionTheultimategoalofscientiﬁcresearchistoexplainphenomena,whichimpliesestab-lishingacausalrelationshipbetweenaspeciﬁcphenomenonanditscause.Inthispaper,wewillfocusontheuseofcausallanguagewheninterpretingtheﬁndingsofresearchintheﬁeldofspirituality,religion,andsubstanceabuse.Writtenlanguageisthemediumthroughwhichwetransferknowledgeobtainedfromascientiﬁcstudy,anditshouldbeusedinaccordancewiththemethodsemployedfordatacollectionandanalysis.However,somestudiesuselanguageinappropriately,implyingcauseandeffectrelationshipsbetweenvariableswhenthemethodsemployedareunsuitableforthispurpose.Thiscanmisleadreaders,especiallythoseuntrainedinresearchmethods,suchasmembersofthegeneralpublic,reporters,orpoliticians.Asscientiﬁcclaimsofcausalityhaveaconsiderableimpactnotonlyonotherscientistsbutalsoongeneralopinion(Halletal.2019),socialmedia(Haberetal.2018),andsocialandhealthpolicies,theuseofappropriatelanguageiskeytoscientiﬁcwriting.1.1.TheRoleofMethodologicalDesigninCausalInferencesVariouscategorieshavebeenproposedtoclassifystudiesaccordingtomethodologicaldesign.Nevertheless,inessence,allclassiﬁcationscanbedividedintotwobroadcategories:Religions2021,12,1075.https://doi.org/10.3390/rel12121075https://www.mdpi.com/journal/religions
Religions2021,12,10752of10experimentalandnon-experimentalstudies.Theformerisendowedwithgreaterinternalvalidity,andthereforethecapacitytoestablishacausalrelationshipbetweenthestudyvariables,evenwhenthisisapracticalinference(CookandCampbell1979,1986;Shadishetal.2002).Theinferentialsuperiorityofrandomizedcontrolledexperiments(referredtoasex-periments)overquasi-experimentsornon-experimentaldesignshasbeenwellarguedoverthedecades(CampbellandStanley1963;CookandCampbell1979).CampbellandStanley(1963)triedtorenewemphasisonexperimentsastheonlymeansforsettlingdisputesregardingeducationalpractice,astheonlywayofverifyingeducationalimprovements,andastheonlywayofestablishingacumulativetraditioninwhichimprovementscanbeintroducedwithoutthedangerofafaddishdiscardofoldwisdominfavorofinferiornovelties(p.2).Inexperimentaldesigns,wemanipulatetheindependentvariable(IV,thepresumedcause)beforepotentiallyobservingavariationinthedependentvariable(DV,thepresumedeffect),whilerulingoutalternativeexplanationsofthatvariation—ifany—bycontrollingfortheextraneousvariables.However,non-experimentalstudies(alsocalledobservational,non-randomized,epidemiologic,orcorrelationalstudies)arealsouseful.Infact,sometimesmanipulationoftheIVisnotpossible(orethical)andanon-experimentalmethodologyistheonlymeanstostudytherelationshipamongvariables,althoughitonlyenablesustodrawconclusionsaboutthedirectionandsizeofthatrelationship.Inotherwords,non-experimentaldesignsdonotallowstatementsaboutcausation.Quasi-experimentaldesignsliesomewhereinbetween.Theyconsistofexperimentaldesignsinwhichsubjectsarenotassignedtoconditionsatrandom,buttheindependentvariablecanbeactivelymanipulatedbytheresearchers.Theysharetheobjectiveofexperimentaldesignsbuthavelessinternalvalidity.Wecanimprovethecasualinferencesaquasi-experimentisabletosupportbyaddingstructuraldetailssuchascontrolgroupsorpretestorposttestmeasures.However,asaquasi-experimentalcontrolgroupmaydifferfromthetreatmentgroupinmanyways,itisalwayspossibletoproposealternativeexplanationsofvariationinthedependentvariableotherthantheeffectoftheindependentvariable.1.2.QuestionableResearchPracticesandCausalLanguageTheuseofinappropriatecausallanguageinnon-experimentalstudiesremainsanissueinseveral(ifnotall)scientiﬁcdisciplines.Thapaetal.(2020)addressedthistopicinclinicalandnursingsettings,whileLiptonandØdegaard(2005)didsoconcerningresultsinepidemiology.Coﬁeldetal.(2010)reviewed525non-experimentalstudiespublishedin2006inthefourhighestrankingjournalsintheﬁeldofnutritionandobesity.Theyfoundcausallanguageinthetitleandorabstractof31%ofthereviewedpapers,insomecaseseveninstudieswithnosigniﬁcantresults(i.e.,withps0.05).Yuetal.(2019)analyzedover29,000non-experimentalstudiespublishedinPubMedusingamachinelearningpredictionmodeltrainedinhealthissues(nutrition,diabetes,obesity,breastcancer,andcholesterol);theyfounddirectcausallanguagein32.4%ofthestudies.Varadyetal.(2021)foundcasuallanguagein60%of400observationalorthopedicstudies.Thistendentiouslanguagemayberelatedtolackoftrainingorapoorunderstandingofresearchmethodsbutmayalsobeduetogrowingcompetitioninacademicinstitutions.Asthenumberofpublications—andtheimpactfactorofthejournalstheyarepublishedin—isoneoftheparametersusedtoevaluatearesearcher’scareer,scientistsareunderpressuretoproduce“publishable”papers,whichareostensiblythosewithsigniﬁcant,relevant,andnovelresults.This“publishorperish”cultureinacademiaisfurtheraccentuatedinthemostcompetitiveacademicenvironments(Fanelli2010),andsuchcompetitionmayjeopardizetheintegrityofscientiﬁcresearch(Andersonetal.2007).Questionable(orbad)researchpracticesareknowntobeathreattothecredibilityofscientiﬁcresearch(Banksetal.2016;Xieetal.2021),andmayoccurnotonlyduringstatisticalanalyses,butalsobefore,during,orafterresearch(PichoandArtino2016)throughtheuseofinadequate
Religions2021,12,10753of10techniques,cherrypicking,p-hacking,variableslicing,notpublishingnegativeresults,etc.(Wichertsetal.2016).1.3.AnAppliedSetting:Spirituality,Religion,andSubstanceAbuseTheroleofpsychologicalandsocialaspectsinhealthissuesiswellknown.Someauthorshavespeciﬁcallystudiedspiritualityandreligiousnessasrelevantvariablesinthisregard(e.g.,Contradaetal.2004;Koenigetal.2012;Saizetal.2020),andreligiousnessisconsideredarelevantvariableinhealthimprovement(Bergin1991;Koenigetal.1993;Steffenetal.2001).Religionhasbeendeﬁnedas“anorganizedsystemofbeliefs,practices,rituals,andsymbolsdesigned(a)tofacilitateclosenesstothesacredortranscendent(God,higherpower,orultimatetruth/reality)and(b)tofosteranunderstandingofone’srelationshipandresponsibilitytoothersinlivingtogetherinacommunity”(KingandKoenig2009,p.2).TheconceptofatranscendenthigherpowervariesfromWesterntoEasterntraditions.Spirituality,meanwhile,isabroaderconceptthatrangesfromacharacteristicthatwecouldusetoidentifydeeplyreligiouspeople(Koenigetal.2012),toadescriptiveaspectofsuperﬁciallyreligiouspeople,religiousorwell-beingseekers,andevensecularindividuals(Koenig2008).Spiritualbeliefsandpracticeshavebeenlinkedtorecoveryfromotherhealthandbehavioralproblems,suchasgamblingdisorder(Gavriel-Friedetal.2020;Gutierrezetal.2020).Theseproblems,althoughsometimeslabeledasaddictions,arenotdirectlyrelatedtosubstanceabuse,andthereforewillnotbeconsideredinthispaper.SubstanceusedisordersarerecognizedintheDSM-5(AmericanPsychiatricAssociation2013)asapatternofproblematicsymptomsderivedfromsubstanceuse.Theycover11criteria,whichincludetakingmoreofasubstancethanyouaresupposedto,notmanagingtocutdown,spendingalotoftimeonactivitiesrelatedtothesubstance,experiencingcravingsforthesubstance,notmanagingtodoeverydaytasksorgivingupotheractivitiesbecauseofit,continuingtousethesubstanceevenwhenitcausesproblems(psychological,inrelationships,orphysicaldanger),anddevelopingtoleranceandwithdrawalsymptoms.Therangeofsubstancesiswide,fromcommonlegaldrugssuchasalcohol,caffeine,ortobaccotocannabis,hallucinogens,opioids,anxiolytics,stimulantssuchascocaine,andevenother,unknownsubstances.Atpresent,treatmentnetworksincludeharmreductionprograms,recovery/therapeuticcommunityprograms,andpsychosocialintegrationprograms(Bestetal.2017).Recoveryprogramshavelongbeenidentiﬁedwiththerapeuticcommunities,butnowalsoincludepeersupport,empowerment,socialsupport,andactiveparticipation(Best2012)ratherthansolelythepresenceorabsenceofsubstances.Healthsystemtherapyinterventionisusuallybasedonanindividualapproach(cognitivebehavioraltherapy)thatincludesrelapseprevention.Otherkindsofservices,suchaspsychosocialsupport,self-helpgroups,peer-supportgroups(socialsupportprograms),supportingprograms,andinterventionwithminorities,canbedifﬁculttointegrateintreatmentnetworks.Anotherfacetnotusuallyincludedintreatmentisspirituality.Spiritualityhasbeenrelatedtoimprovementinsomehealthoutcomes,includingstateanxietyinalcoholrecovery(Andóetal.2016)andrelapseprevention(Maguraetal.2013),inthecontextofrecoveryinterventionssuchasthe12-stepprogramsofAlcoholicsAnonymous,whichadvocateacceptanceofa“higherpower”,promotespiritualawakening,anduseprayerandmeditationastoolsforrecoveryandhealing(AlcoholicsAnonymous2001).Usingmultipledatabases,weconductedasystematicreviewtoobtainanon-biasedsampleofnon-experimental(observational)studiesthatlinkedtreatmentsorinterventionsbasedonspirituality(whichincludesreligion)toanimprovementinsubstanceabusedisor-ders(includingrelapseprevention).Then,wedescribedthevalidityofreportedstatementsabouttherelationshipbetweentheseinterventionsandsubstanceabuseoutcomes.
Religions2021,12,10754of102.MethodsWefollowedthePreferredReportingItemsforSystematicReviewsandMeta-Analyses(PRISMA)guidelines(Pageetal.2021)forthesystematicreviewprocedure.2.1.EligibilityCriteriaTobeincludedinthereview,thestudieshadtobescientiﬁcpaperspublishedbe-tween2015and2020,inSpanishorEnglish.Thestudiesalsohadtomeetthefollowinginclusioncriteria:(a)non-experimentaldesigns,(b)usingparticipantswithaproblemofsubstanceabuse(anysubstance),(c)atleastoneinterventiongroup,(d)aninterventionprogrambasedonspiritualorreligiousbeliefs,and(e)thestudypresentedatleastoneoutcomemeasureassessingtherelationshipbetweentheinterventionandadecreaseintheabuse,relapseprevention,oratheoreticallyrelatedvariable.Studieswithnon-signiﬁcantoutcomesandqualitativemethodologieswereexcluded.2.2.InformationSourcesWeconductedasystematicliteraturesearchforrelevantstudiesusingseveralProQuestdatabases(PsycINFOandtheSociologyCollection,whichincludestheSociologyDatabase,AppliedSocialSciencesIndex&Abstracts[ASSIA],andSociologicalAbstracts),Scopus,andPubmed,fortheperiod2015to2020.2.3.SearchStrategyWeenteredthesamesearchtermsineachselecteddatabase,inEnglishandSpanish,usingtheBooleanexpression“(addictionOR“substanceabuse”)AND(spiritualityORspiritual)AND(relapseORtreatment)”,adaptedtothespeciﬁcsyntaxrulesofeachdatabase.Werestrictedthesearchbytitle,abstract,andkeywords.Wealsorestrictedthesearchtopeer-reviewedscientiﬁcpapers,excludingtheses,dissertations,books,andgrayliteraturereports.Anotherrestrictionwasthepublicationdate,from2015to2020(bothinclusive).2.4.SelectionProcessTherecordsobtainedinthepreviousstepwereenteredintoasingleExcelspread-sheet,usingitsbuilt-intoolstodetectandeliminateduplicaterecords.Tworeviewersindependentlyscreenedeachrecordbytitleandabstracttoassesswhetheritwassuitableforretrievalandreading.Disagreementbetweenthereviewerswasresolvedbyconsensusand,wherenecessary,theﬁnaldecisionwasreachedwiththehelpofathirdresearcher.2.5.DataCollectionProcessAlleligiblerecordswereretrieved.Thesereportswerereadbythetworeviewerstodetermineﬁnalinclusionanddataextraction.2.6.DeterminationofCausalLanguageBothreviewersindependentlysearchedforthepresenceoflanguageimplyingcausa-tioninthetitle,abstract,ordiscussionsectionofeachreport.Thelanguageusedwascodedseparatelyfortitle,abstract,anddiscussion,inthreedistinctcategories:“Correct”ifcasuallanguagewasnotusedinnon-experimentalstudies;“tendentious”whenanon-experimentalstudyincludedambiguousexpressionsthatcouldbeinterpretedasimplyingcausation;and“incorrect”whereexpressionsclearlysuggestedcausalrelationshipsbetweenvariablesinnon-experimentalstudies.Whenwefoundmixedcategoriesinagivenstudy,itwasclassiﬁedintheworstcategoryassigned.Inaddition,thereviewerssearchedfordisclaimerspresentedimmediatelyaftercausalexpressions,disavowingcausationinnon-experimentaldesigns(forinstance,suggestingalternativeexplanations).Whensuchadisclaimerwaspresent,thestudywasclassiﬁedas“correct”.Asinthepreviousstep,disagreementswereresolvedbyconsensusandwiththehelpofathirdresearcher.
Religions2021,12,10755of103.Results3.1.StudySelectionFigure1showstheﬂowchartofthesearchandselectionofstudies.Atotalof477studieswereidentiﬁed,and294non-duplicaterecordswerescreened.Afterexcluding269records(241bytitleand28byabstract),24wereretrievedandassessedforeligibility.Somearticleswereexcludedforseveralreasons:thestudiesusedexperimental(McClintocketal.2019;TemmeandKopak2016;Yeterianetal.2018)orquasi-experimental(Malliketal.2019)designs;theoutcomewasnon-signiﬁcant(Webster2015;Yeterianetal.2015)orwasnotrelatedtodecreaseinsubstanceabuseorrelapseprevention(Lunaetal.2016);theinterventionwasnotspirituallybased(Nurulhudaetal.2018).Finally,16studieswereincludedinthereview.Figure1.FlowchartofthesearchandselectionofstudiesbasedonthePRISMAStatement(Pageetal.2021).3.2.StudyCharacteristicsWefounddifferentdesignsinthesixteenstudiesselected:Cross-sectional,sixstudies(37.5%)(AbdollahiandTalib2015;CrutchﬁeldandGüss2018;Dickersonetal.2021;KellyandEddie2020;Medlocketal.2017;Shoreyetal.2015);longitudinal,ﬁvestudies(31.3%)(Lashley2018;Leeetal.2017;MontesandTonigan2017;Ranesetal.2016;Ransomeaetal.2019);pre-experimental(one-grouppretest-posttestdesign),fourstudies(25.0%)(Becksteadetal.2015;Kerlin2017;Saarietal.2020;Tianingrumetal.2019);andonestudy(6.3%)usedathreestatic,non-equivalentgroupsdesign(Andóetal.2016).Bytitle,13studies(81.3%)werecodedas“correct”,onestudy(6.3%)as“tendentious”,andtwostudies(12.5%)as“incorrect”.Byabstract,sevenstudies(43.8%)werecodedas“correct”,fourstudies(25.0%)as“tendentious”,andﬁvestudies(31.3%)as“incorrect”.Inthediscussionsectiontheresultswerethesameasbyabstract,(43.8%“correct”,25.0%“tendentious”,and31.3%“incorrect”).Wefoundadisclaimerdisavowingcausationintwo
Religions2021,12,10756of10occasions;forinstance,“…randomizedandfollow-upstudiesareneededtoclarifytheinterrelationshipbetweenspiritualorientationandmentalhealthstatusindices.”(Andóetal.2016,p.5).However,thedisclaimerswerenotlocatedimmediatelyfollowingcausalclaims,butinanothersection.Takingintoaccountallthreesectionsaltogether,sixstudies(37.5%)usedcorrectex-pressionsinallsections;ﬁvestudies(31.3%)usedtendentious(butnotincorrect)languageinatleastonesection;ﬁvestudies(37.5%)usedincorrectlanguageinatleastonesection;andonlytwostudies(12.5%)usedincorrectlanguageinallthreesections,title,abstract,anddiscussion.Table1showsexamplesoftendentiousandincorrectexpressions.Table1.Verbatimexamplesoftendentiousandincorrectcausallanguageinthestudiesselected.TendentiousIncorrect“…hardinessmaybeaprotectivefactorforindividualswithsubstanceabuse…”“Objective:Todeterminetheimpactoflengthofstay…”“Itispossiblethatmindfulness-basedinterventionsmayhavetheconcurrentbeneﬁtofreducingsubstanceuse…”“Faith-basedprogramsplayavitalroleinthetreatmentofsubstanceusedisorders.”“Mindfulness-basedinterventionsmayholdpromiseasaneffectiveinterventionforreducingsubstanceuse…”“…isahealthysignthatShalomRecovery’streatmentprotocolishavingapositiveandtherapeuticeffect…”“…youthswithlowservice,withorwithouthighlove,weremorelikelytorelapsethan…”“ThestudyshowsthatreligionandspiritualteachingsspeciﬁcallySuﬁtechniquesareimportanttotherehabilitationofdrugaddicts.”“…itislikelythatStep-workplayedakeyroleinfosteringchange.”“ThestudyalsoconcludesthatSuﬁHealingTherapyModelareeffectivetobeusedondrugaddicts…”“…Spiritualvirtueasapathwaytowards[…]recovery…”“…NAmeetingproducemorepositiveeffecttowardrelapseprevention…”“…suggestsinterventions[…]mayimproverelapseprevention…”“Theroleofspiritualityinthedecreaseofstateanxietyindicatesacutebeneﬁcialeffect”.“…interventionsapplyingspiritualitycouldhelprelapseprevention…”“…attendingNAmeetingonceaweekgaveasigniﬁcantchange…”“Religiousinvolvementmaybeimportantforpreventionandtreatmentpractices…”“Theimpactoflengthofstayonrecoverymeasures…”Note:Italicsaddedtohighlighttermsthatimplycausation.4.DiscussionThispaperdiscussestheimportanceofonlyusingcausallanguageinresearchpaperswhenthemethodologyemployedintheresearchsupportsthecausalclaims.Weconductedasystematicreviewofaspeciﬁchealth-relatedtopictoillustrateourpointinanappliedsetting.Westudiedwhethernon-experimentalstudiesonspiritualorreligiousinterven-tionsinsubstanceabusewerewrittenusingappropriatelanguage,oriftheycontainedambiguous,tendentious,orevenoutrightincorrectcausalclaims.Roughlyathirdofthestudiesselectedusedacorrectlanguageintitle,abstract,anddiscussionsections.Theremainingstudiesusedtendentiousorincorrectlanguageinatleastonesection,approximatelythesameproportionthatVaradyetal.(2021)foundinobservationalstudies.Ifweconsideronlyincorrectlanguage,ourresultsaresimilartothosefoundinotherscientiﬁcdisciplines(Coﬁeldetal.2010;Yuetal.2019).Thus,thetopicofinappropriatecausalclaimsisalsoanissueinnon-experimentalresearchonspirituality-basedinterventions.Theliteraturecontainspromisingdataonspiritualityinrecovery-orientedprograms—especiallythoseemployingaparticipativeactionapproach,abiopsychosocialperspective,andasocialsupportandrecoverycapitalfocus—intermsoftreatment,socialreintegration,
Religions2021,12,10757of10andrelapseprevention(Best2012;Bestetal.2017).Thedevelopmentofanycompletetreatmentnetworkforaddictivebehaviorsmustincludeprogramsbasedonpreviouslyvalidatedevidence.ThisproposalcoincideswiththerecommendationsgivenintheQualityStandardsforDrugDependenceTreatmentandCareServicesissuedbytheUnitedNationsOfﬁceofDrugsandCrime(UNODC2012).However,weshouldnotconfusepromisingdatalinkingspiritualinterventionsforsubstanceabuserecoveryandrelapsepreventionwiththeclaimthattheformerisresponsibleforthelatter.Withoutthesupportofanexperimentalmethodology,otheralternativeexplanationscouldbeproposed,suchasotherinformalsocialsupportnetworks,greaterindividualmotivationtochange,oranyotherbehavioralpatternthatfavorsimprovement.Asinglestudycannotconﬁrm—orreject—anysubstantivehypothesis,regardlessofitsstatisticalsupport(Harcum1990),evenifanexperimentalmethodologyhasbeenused.However,awell-controlledexperimentaldesignmaycontaincausalclaimsabouttherelationshipsofthespeciﬁcvariablesincludedinthatstudy.Ontheotherhand,multiplenon-experimentalstudiescancontribute(theyusuallydo)toaccrueevidencesupportingcause–effectrelationships,butnosinglenon-experimentalstudymaycontaincausalclaims.Alltheseconsiderationsapplytoanyscientiﬁcﬁeld,includingempiricalstudiesonreligionorspirituality.Severalworkshavesummarizedreportingstandardsforscientiﬁcpublication(e.g.,AmericanPsychologicalAssociation2019;Appelbaumetal.2018;Levittetal.2018),andvarioushandbooks(e.g.,Cohenetal.2018;Hancocketal.2019)havealsocoveredthistopicextensively.Thesetextsthusprovideappliedresearchersinthehealthandsocialscienceswithcomprehensiveguidelinesonselectingthemostsuitablemethodtodesignastudyinlinewiththeirspeciﬁcinterests.Useoftheseguidesshouldinstructresearchersoftheconsequencesoftheirchoices,eveniftheyhavenospeciﬁctraininginmethodologyorresearchmethods.4.1.LimitationsTherearesomelimitationstoourstudy.First,wesearchedforaveryspeciﬁcsubject—spiritualinterventions—andtheireffectonrelapseinsubstanceabuse,andthesearchtermsweusedwerelimited.Inaddition,weonlyreviewedasmallnumberofpapers(n=16)consideredsuitableaccordingtotheinclusionandexclusioncriteria.Wecouldhavecarriedoutasearchwithdifferentparameters:moredatabases,awiderrangeofpublicationdates,synonymoussearchterms,etc.,inordertoobtainalargersampleofpapers.Wecouldevenhavesearchedpapersrelatedtoabroadersubject,suchastheeffectivenessofspiritualinterventionsonseveralhealthvariables.However,themainobjectivewastoaddresstheimportanceofusingappropriatelanguageinscientiﬁcpapersontheissueofspiritualinterventions.Thesystematicreviewwascarriedouttoobtainanon-biasedselectionofarticles.Furthermore,thereisnoevidencethatourchosenresearchtopicisaddresseddifferentlythananyother.Nevertheless,weshouldbecautiousaboutgeneralizationbasedonourlimitedresults.Furtherstudiesmaytacklethissameobjectiveusingadifferentappliedresearchquestion.4.2.ConclusionsScientiﬁcclaimsaboutagivenstudymustbeinaccordancewiththemethodologyused.Theinappropriateuseofcasuallanguagemaymisleadreadersintoassumingacausalrelationshipbetweenindependentanddependentvariableswhenitisnotpossibletoruleoutalternativeexplanations.Therefore,theuseofinappropriatecausallanguageisattheveryleastnegligent(whenitiscausedbylackoftraininginresearchmethodsorscientiﬁcreporting),andbadpraxiswhentheauthorsaretryingtooverstatetheimportanceoftheirresults.Readersshouldbewarned:Casualexpressionsinpublishedpeer-reviewedarticles(particularlywheninthetitleorabstract)maynotbebackedupbysolidexperimentalmethodology.Evenwheninahurry,readersshoulddevotesometimetoassessingthe
Religions2021,12,10758of10design,analyses,andinterpretationofastudy;thisistheonlywaytodeterminewhetheraninferenceofcausationisaccurateandappropriate.Researchersshouldbeencouragedtorevisesubmissionsformisleadingreporting,particularlywhenhighlightingthemainﬁndingsandwhensummarizingtheminthetitleandabstract.Studiesontheeffectivenessofspiritualinterventionsinhealthissues,suchasrelapseinsubstanceabuse,havebuiltupapromisingbodyofevidence.Inanon-experimentaldesign,toconcludethataspirituallyorientedinterventionisrelatedtoalowerrelapseincidence—inplainlanguage,thatitseemstobeeffective—isnotademeritoftheresearch.Onthecontrary,honestywheninterpretingresultsleadstomorerigorousscienceandshouldbealwayswelcomed.AuthorContributions:Conceptualization,I.S.-I.andM.G.-C.;methodology,I.S.-I.;formalanalysis,M.G.-C.;investigation,A.J.M.andI.S.-I.;writing—originaldraftpreparation,M.G.-C.;writing—reviewandediting,I.S.-I.;supervision,I.S.-I.andA.J.M.Allauthorshavereadandagreedtothepublishedversionofthemanuscript.Funding:Thisresearchreceivednoexternalfunding.InstitutionalReviewBoardStatement:Notapplicable.InformedConsentStatement:Notapplicable.DataAvailabilityStatement:Notapplicable.ConﬂictsofInterest:Theauthorsdeclarenoconﬂictofinterest.ReferencesAbdollahi,Abbas,andMansorAbuTalib.2015.Hardiness,spirituality,andsuicidalideationamongindividualswithsubstanceabuse:Themoderatingroleofgenderandmaritalstatus.JournalofDualDiagnosis11:12–21.[CrossRef][PubMed]AlcoholicsAnonymous.2001.AlcoholicsAnonymous,theBigBook,4thed.NewYork:A.A.WorldServices.AmericanPsychiatricAssociation.2013.DiagnosticandStatisticalManualofMentalDisorders,5thed.Arlington:AmericanPsychiatricPublishing.[CrossRef]AmericanPsychologicalAssociation.2019.PublicationManualoftheAmericanPsychologicalAssociation,7thed.Washington,DC:AmericanPsychologicalAssociation.Anderson,MelissaS.,EmilyA.Ronning,RaymondDeVries,andBrianC.Martinson.2007.ThePerverseEffectsofCompetitiononScientists’WorkandRelationships.ScienceandEngineeringEthics13:437–61.[CrossRef][PubMed]Andó,Bálint,PéterZoltánÁlmos,ViolaL.Németh,IldikóKovács,AnnaFehér-Csókás,IldikóDemeter,SándorRózsa,RóbertUrbán,EszterKurgyis,ZoltánJankaPetronellaSzikszay,andetal.2016.Spiritualitymediatesstateanxietybutnottraitanxietyanddepressioninalcoholrecovery.JournalofSubstanceUse21:344–48.[CrossRef]Appelbaum,Mark,HarrisCooper,RexB.Kline,EvanMayo-Wilson,ArthurM.Nezu,andStephenM.Rao.2018.Journalarticlereportingstandardsforquantitativeresearchinpsychology:TheAPAPublicationsandCommunicationsBoardtaskforcereport.AmericanPsychologist73:3–25.[CrossRef]Banks,GeorgeC.,StevenG.Rogelberg,HaleyM.Woznyj,RonaldS.Landis,andDeborahE.Rupp.2016.Editorial:EvidenceonQuestionableResearchPractices:TheGood,theBad,andtheUgly.JournalofBusinessandPsychology31:323–38.[CrossRef]Beckstead,D.Joel,Michael.J.Lambert,Anthony.P.DuBose,andMarshaLinehan.2015.DialecticalbehaviortherapywithAmericanIndian/AlaskaNativeadolescentsdiagnosedwithsubstanceusedisorders:Combininganevidencebasedtreatmentwithcultural,traditional,andspiritualbeliefs.AddictiveBehaviors51:84–87.[CrossRef][PubMed]Bergin,AllenE.1991.Valuesandreligiousissuesinpsychotherapyandmentalhealth.AmericanPsychologist46:394–403.[CrossRef]Best,David.2012.AddictionRecovery:AMovementforPersonalChangeandSocialGrowthintheUK.Brighton:PavilionPublishing.Best,David,Ana-MariaBliuc,MuhammadIqbal,KatieUpton,andSteveHodgkins.2017.Mappingsocialidentitychangeinonlinenetworksofaddictionrecovery.AddictionResearch&Theory26:163–73.[CrossRef]Campbell,DonaldT.,andJulianC.Stanley.1963.ExperimentalandQuasi-ExperimentalDesignsforResearch.RavenioBooks.Availableonline:https://www.amazon.com/Experimental-Quasi-Experimental-Designs-Research-Campbell/dp/0395307872(accessedon11November2021).Coﬁeld,StaceyS.,RachelV.Corona,andDavidB.Allison.2010.Useofcausallanguageinobservationalstudiesofobesityandnutrition.ObesityFacts3:353–56.[CrossRef]Cohen,Louis,LawrenceManion,andKeithMorrison.2018.ResearchMethodsinEducation,8thed.Abingdon-on-Thames:Routledge.Contrada,RichardJ.,TanyaM.Goyal,CorinneCather,LubaRafalson,EllenL.Idler,andTyroneJ.Krause.2004.Psychosocialfactorsinoutcomesofheartsurgery:Theimpactofreligiousinvolvementanddepressivesymptoms.HealthPsychology23:227–38.[CrossRef]
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PsychotherapyVolume 30/Summer 1993/Number 2RELAPSE PREVENTION MODELS FOR SUBSTANCEABUSE TREATMENTRICHARD A. RAWSONUniversity of California, Los AngelesRelapse prevention (RP) techniques havebeen integrated into numerous aspects ofsubstance abuse treatment and research.One of the most promising uses ofRPtechniques is to provide a conceptualframework for the delivery of outpatientdrug-free substance abuse treatment. Anumber of writers and researchers haveproduced models of treatment using RPprinciples as the central philosophy andmethodology. Several writers havecreated descriptive models which outlineclinical recommendations on the uses ofRP methods for substance abusetreatment. A number of researchers havecreated drug specific protocols whichhave allowed for the evaluation ofspecific RP methodologies with specificclinical populations. A third set ofclinical researchers have combined RPtechniques with other types of treatmentmaterials to create integrated outpatientmodels of treatment. These modelsprovide the field of substance abusetreatment with a clear framework fordelivering outpatient substance abuseThis work is supported in part by Grants: #1R18DA06185-01, #R44DA05778-02and#l R18DA05661-03fromNIDAto Matrix Center, Friends Medical Science Research Center,and San Diego State University, and Grant # R43 AA08971-01 from N1AAA to Matrix Center.Correspondence regarding this article should be addressedto Richard A. Rawson, Matrix Institute on Addictions, 8447Wilshire Blvd., Ste. 409, Beverly Hills, CA 90211.JEANNE L. OBERTMICHAEL J. McCANNPATRICIA MARINELLI-CASEYLos Angeles, Californiatreatment. They are structured in such away as to promote replication andevaluation. The development of this setof models allows for the systematicadvancement of outpatient drug-freesubstance abuse treatment.Drug-free outpatient treatment is one of themost widely used, but poorly evaluated, modal-ities for the treatment of substance abuse disorders(Hubbard et al., 1989). One of the most problem-atic aspects of evaluating these treatment pro-grams has been that they consist of a heteroge-neous group of techniques which are unstand-ardized and are without clear treatment protocols.As the addiction treatment field attempts to estab-lish an empirical foundation, it has become in-creasingly important to create drug-free treatmentprotocols which can be clearly defined, repli-cated, and evaluated. As attempts are made toforecast the types of treatment resources neededfor substance abuse treatment in the 1990s, it willbe useful to clarify the role that outpatient drug-free treatment will play in the evolving system.During the 1980s, a number of investigatorscreated standardized outpatient drug-free treat-ment models and protocols which can be repli-cated and evaluated. A common thread to thesemodels is the use of a set of techniques whichhave a theoretical basis in social learning theory(Bandura, 1977, 1981, 1982). The techniques in-cluded within these models have been derivedfrom a cognitive-behavioral framework and havebeen categorized as relapse prevention strategies(Marlatt & Gordon, 1985).These techniques are appealing to clinical re-searchers in the field of substance abuse treatment284
Relapse Prevention Modelsbecause they have a solid conceptual foundationand can be empirically evaluated. Use of thesemodels and techniques provides outpatient drug-free treatment with a clear theoretical and method-ological focus and allows for the systematic de-velopment of protocols which can be replicatedand evaluated.The term relapse prevention is defined asfollows:Relapse Prevention (RP) is a generic term that refers to a widerange of strategies designed to prevent relapse in the area ofaddictive behavior change. The primary focus of RP is on thecrucial issue of maintenance in the habit-change process. Thepurpose is twofold: to prevent the occurrence of initial lapsesafter one has embarked on a program of habit change, and/or to prevent any lapse from escalating into a total relapse.(Marlatt & Gordon, 1985)Relapse Prevention Content AreasThe techniques which have been used withinthe designation of the RP category include thefollowing groups of strategies:1. Psychoeducation—An important ingredientin most of the RP models is the use of informationand education about a variety of addiction-relatedtopics. Central among the issues taught to sub-stance abusers during the course of treatment arethe following topic areas: brain chemistry andaddiction; conditioned cues and craving; drug andalcohol effects; addiction as a biological disorder;drug use and AIDS; addiction and the family;need for lifestyle change; relationships betweensubstance abuse and other compulsive disorders.The psychoeducational material is often presentedin classroom format or group discussion and isintegrated into individual counseling sessions.Many of the models use videotape and slide pre-sentations and provide clients with written materi-als to encourage review of educational materials.2. Identification of high risk situations for re-lapse and warning signs for relapse—Clients aretaught that there are behaviors and environmentsas well as cognitive and affective states whichare associated with drug/alcohol use. Through in-dividual and group discussion, as well as in home-work assignments, clients are assisted in learningthe specific set of conditions which have the great-est association with drug/alcohol use. Some ex-amples of these conditions are:High Risk States—certain times of day, being around drugusing friends, bars, the presence of money, idle time.Behavioral Warning Signs—”addict” behavior, compul-sive and impulsive behavior, time with drug users, stoppingrecovery activities, returning to secondary drug use.Cognitive Warning Signs—euphoric recall, relapse justifi-cation, drug dreams, rationalizations to discontinue new re-covery behaviors.Affective Warning Signs—periods of emotionality pre-viously associated with drug use.• Positive affective states (e.g., excitement, arousal,celebration)• Negative affective states (e.g., depression, loneliness,anger, boredom)3. Development of coping skills—It is hypothe-sized in these models that substance abusers havemaladaptive coping skills when placed in high-risk situations. Much of the individual and group”counseling” is focused upon teaching and rein-forcing alternative responses which will not leadto drug/alcohol use. These new coping skills arediscussed in sessions. Options are explored and,in some cases, new skills are role-played and/orhomework assignments are given to practice thenew coping response. Examples of these copingskills include: how to say “no” to an offer ofdrug/alcohol use; types of alternative behaviorsto engage in during high risk periods (e.g., exer-cising rather than going to “happy hour”); meth-ods of expressing affective states rather than usingdrugs or alcohol; new cognitive strategies, suchas thought-stopping, to avoid drug thoughts andcraving.4. Development of new lifestyle behaviors—Once drug/alcohol use has been suppressed, it isviewed as useful to reinforce the development ofalternative activities to serve as intrinsic rein-forcers of abstinence. Group discussions andhomework assignments are used to assist drug/alcohol users in acquiring and maintaining newleisure, recreational and employment activitieswhich will support a non-drug-using lifestyle. Ex-ercise, hobbies, family activities, community ac-tivities, and self-help involvement are the typesof activities which are reinforced by program staffand group peers.5. Increased self-efficacy—According toBandura’s theory of self-efficacy, the methodsthat initiate behavior change may not be the bestmethods for producing generalized change or longterm change (Bandura, 1977, 1981, 1982). Thisself-efficacy theory proposes that when peopleenter high-risk situations for drug or alcohol use,they choose each response based upon their ap-praisal of their ability to cope with the situation.If they view themselves as competent they willabstain from using drugs and alcohol. If not com-petent, they are at increased risk to use. In orderto facilitate the development of the self-perception285
R. A. Rawson et al.of competence, clients are given homework as-signments which involve entering highrrisk situa-tions and employing new responses. It is hypothe-sized that repeated success in coping with thesesituations in new, non-drug/alcohol using wayswill increase self-perception of competence andself-efficacy. The development of this self-effi-cacy is viewed as critical to long-term abstinence.This method is typically employed in group set-tings, with homework assignments of graduallyincreasing difficulty as the essential treatment ex-ercise. In some situations rehearsal and role-play-ing are used to prepare the client.6. Dealing with relapse—Avoiding the absti-nence violation effect—Within these models, thereality of relapse is addressed. Clients are taughtto view return to drug/alcohol use as “slips” or”lapses” that need not lead back to full-blownrelapse and readdiction. This cognitive reframingof a lapse from a catastrophe into an opportunityto learn how to improve the treatment plan re-duces the shame and failure often experienced inthe event of a slip or lapse. This approach indealing with a return to alcohol/drug use can inter-rupt the cycle where a lapse turns into an extendedrelapse episode.7. Drug/alcohol monitoring—Although notspecifically a RP technique, these models allmake use of urine and breath testing to monitordrug and alcohol use. These techniques areviewed as critical for promoting client account-ability and they serve as a dependent measure ofprogram effectiveness.Types of Relapse Prevention ModelsThe content areas are used in different combi-nations and intensities in the treatment modelsdescribed in this paper. Not all models use allcomponents and some models are additional tech-niques which do not fall under the general classi-fication of RP techniques. However, all the mod-els described view addressing the issue of RPfrom a cognitive-behavioral orientation as definedby Marlatt & Gordon (1985) as a central part ofsubstance abuse recovery. This paper describesRP models which have been used for the treat-ment of substance abuse disorders. Due to thelimitations of space, models for the treatment ofnicotine dependence have been omitted. Threetypes of “relapse prevention models” have beendeveloped to date. These include:Descriptive Models—These models broadly apply RPstrategies to a wide range of substance abuse behaviors. Thesemodels use clinical observations and case studies to illustratethe value of RP strategies in treating substance abuse disor-ders. They are designed to promote application of these tech-niques in applied clinical settings. They do not involve well-defined methodologies and have not received empiricalevaluation.Drug-Specific Protocols—These models use clearly de-fined treatment protocols which are applied to specific typesof substance abuse disorders. The number of treatment ses-sions, the length of treatment sessions, and the content oftreatment sessions are clearly specified. Typically these proto-cols are applied to single categories of substance abuse disor-ders (e.g., cocaine, alcohol, opiates, etc.) and the treatmentoutcome is measured with standardized measurement indices.These protocols have been designed for evaluation in well-controlled research studies. These models have not been de-signed as stand alone programs for clinical implementation.Integrated Outpatient Models—These models utilize manyof the principles and clinical insights described in the descrip-tive models (#1 above) and operationalize them into compre-hensive treatment programs which have been “manualized”for replication and evaluation. In some cases, techniques suchas family therapy and self-help involvement have been addedto the cognitive-behavioral elements. However, in all cases,the structure and emphasis of the models are weighted heavilytoward the use of RP techniques. Many of the methods andoutcome measures used in the drug-specific protocols (#2above) have been incorporated into the design and evaluationof these models. These models have been designed for usein clinical settings as viable outpatient treatment programswhich have replicability and empirical accountability.Each of the three types of models have beenvaluable in developing RP strategies into compre-hensive substance abuse treatment. The descrip-tive models provide clinically relevant treatmentrecommendations and case study examples de-signed to give clinicians valuable treatment mate-rials. The drug-specific, focused protocols allowfor well-controlled research evaluations of indi-vidual components of the RP methodology withspecific clinical populations. The integrated out-patient models attempt to combine multiple RPtechniques into viable, clinically comprehensiveoutpatient treatment models which allow for em-pirical evaluation. The development of the RPapproach through the creation of these variousmodels has greatly enhanced the systematic evo-lution of outpatient drug-free treatment. The fol-lowing review summarizes some current RP mod-els and surveys evaluation data available to date.The Foundation of Relapse PreventionModels—G. Alan Marlatt and Judith GordonThe most conceptually well-constructed modelof RP is the model created by G. Alan Marlattand Judith Gordon (Marlatt & Gordon, 1980). Inthe first five chapters of his book with JudithGordon, Marlatt lays out the foundation for the286
Relapse Prevention Modelsentire field of RP (Marlatt & Gordon, 1985). Thetopic areas presented in this book include: 1. The-oretical rationale and overview of the model; 2.Situational determinants of relapse and skill-train-ing interventions; 3. Cognitive factors in relapse;4. Cognitive assessment and intervention proce-dures; and 5. Lifestyle modification. Although asynopsis of Marlatt’s model is beyond the scopeof this article, there are a number of noteworthykey points which have given direction and impe-tus to the field.Marlatt provides a compelling conceptualiza-tion of addiction as a set of habit patterns whichhave been reinforced by pharmacological and so-cial reinforcement contingencies. Consequently,addiction treatment is a process of habit change.The techniques which have been developed tofacilitate this process have their roots in sociallearning principles. This view of addiction andaddiction treatment is contrasted with the view ofaddiction as a disease, a position widely held bymany, including proponents of the AlcoholicsAnonymous (AA) program. A second importantissue discussed by Marlatt is the nature of relapse.His position that relapse is the result of a predict-able series of cognitive and behavioral eventswhich lead to a return to drug or alcohol use,has been tremendously valuable in demystifyingrelapse. The observation that relapse has clearantecedents and warning signs has provided a per-spective that allows the relapse process to be dis-sected and systematically studied.Marlatt’s work has provided a frameworkwithin which the situations and circumstanceswhich put addicts and alcoholics at high risk forrelapse can be studied. By describing a range ofcoping responses to these high risk situations, hehas given clinicians a broad range of behavioralstrategies for addressing client needs. His applica-tion of self-efficacy principles from the work ofBandura (1977, 1981, 1982) has given addictionresearchers an approach for addressing the cogni-tive aspects of addiction. A related concept de-scribed by Marlatt is the abstinence violation ef-fect. This phenomenon, explained in terms ofattribution theory (Weiner, 1972, 1974, 1976),present a rationale for explaining why addicts andalcoholics often respond to a single lapse by re-turning to a full-blown readdiction episode. Mar-latt has also emphasized the value of using educa-tion and information in the treatment process. Aspart of this educational process he suggests usingmetaphors for explaining addiction and recoveryrelated concepts. Finally, recovery from addictionis conceptualized as a type of lifestyle modifica-tion in which achieving balance and developingalternative behaviors are key ingredients. Mar-latt’s work has provided a foundation for muchof the theoretical and empirical writings on RP.Most of the models described in this article haveborrowed extensively from his writing. His con-tribution to this field is unmatched.Descriptive ModelsGorski’s Cenaps ModelGorski’s Cenaps Model has had a major impactin the private chemical dependency treatment sys-tem. The RP materials developed by Gorski andassociates (Gorski, 1989a,Z>, 1990; Gorski &Miller, 1986; Miller, Gorski, & Miller, 1982)have popularized the use of RP techniques in in-patient chemical dependency units and in com-mercial outpatient treatment settings. Gorski’swork does not have the extensive theoretical foun-dation of Marlatt’s work but it does have a wealthof clinically valuable insights which are presentedin a cognitive-behavioral framework. Gorski’swork has received little empirical evaluation sincethe model describes broad clinical recommenda-tions without presenting a specific format or meth-odology which can be tested in a controlled man-ner. The majority of Gorski’s RP work hasfocussed on alcoholism recovery and more re-cently cocaine addiction. His recognition of theneurological factors in the recovery of alcoholicsand his attention to the post-acute withdrawal syn-drome in recovery have been valuable adaptationsof research findings to clinical practice. By mov-ing RP concepts and terminology into the private,commercial, chemical dependency system, Gor-ski has broadened an approach that was pre-viously exclusively spiritual and emotional. Table1 lists several key aspects of Gorski’s CenapsModel.Wallace’s Relapse Prevention Model for CrackCocaine UsersWallace has reviewed the current body of treat-ment information for cocaine abuse (Wallace,1991). She also has provided a clinical modeladapting RP strategies for use with inner-citycrack smokers (Wallace, 1989; 1990). Many ofthe strategies she describes have been adaptedfrom Marlatt & Gordon (1985) and Gorski &Miller (1982). Her recommendations for imple-287
R. A. Rawson et al.TABLE 1. Goiski’s Cenaps ModelDrug: Alcohol (concepts extrapolated to all chemical dependencies)Format: Individual and/or Group Sessions. Frequency is individualized.Duration: 3 yearsContent: Components:1. Stabilization—Detoxification and practical suggestions presented in sessions to promote and supportinitial abstinence.2. Self-assessment—Review of history of drinking to illustrate damage from drinking. Review relapse historyto understand the patterns of relapse.3. Relapse Education—Films and lectures present information about the “disease” of alcoholism and factorsinvolved in high-risk situations and warning signs for relapse.4. Warning Sign Identification—Patients construct a list of warning signs for relapse. Involves listing theirrational thoughts, unmanageable feelings and self-defeating behaviors that have preceded andaccompanied relapse.5. Coping Skills—Patients engage in skill training to increase their ability to cope with warning signs. Copingskills include: mental rehearsal, role-playing, and therapeutic assignments.6. Recovery Planning—Constructing a set of ongoing activities that will address problems that are associatedwith warning signs. These can include marital counseling, leisure activities, exercise, etc.7. Inventory Training—Creating a daily recovery plan with positive goals and a review of potentialwarning signs.8. Involvement of Others—Significant others (spouses, AA sponsors, employers) are educated about warningsigns and enlisted to support recovery plan.9. RP Plan Update—Monthly plans are created for the first 3 months, quarterly until month 12; semi-annually until 3 years. These sessions review and revise warning signs list, review progress in dealingwith problem-solving, develop new skills for new problem areas, and revise recovery program activity list.menting RP strategies with crack smokers giveclinicians a relevant set of techniques for workingwith this population. Her model has not beenformalized into a specific methodology for evalu-ation. Table 2 provides an overview of the issuesshe emphasizes in her model.Drug-Specific ProtocolsRelapse Prevention Treatment ofAlcoholism—Annis and AssociatesA model for applying RP strategies to the treat-ment of alcoholism has been created by Annisand associates at the Addiction Behavioral Foun-dation in Toronto (Annis, 1986, 1990; Annis &Davis 1988; Annis & Davis 1989). Annis hasused the concepts developed by Marlatt & Gordon(1985) to identify categories of high-risk situa-tions and combined them with the self-efficacytheory of Bandura (1977, 1978, 1986) to teachclients how to resist temptations to drink. Annishas developed two assessment scales, the Inven-tory of Drinking Situations (IDS) and the Situa-tional Confidence Questionnaire (SCQ) which areimportant to her model. The IDS provides clini-cians with an inventory for assessing the situa-tions in which clients are at greatest risk for drink-ing. The SCQ is a self-efficacy measure of aclient’s perceived ability to cope with alcohol-related situations. In this model, knowledge ofthese two dimensions is viewed as critical to thecreation of a client’s RP treatment plan. The ratio-nale for Annis’ model is that once high-risk situa-tions for drinking are identified, it is possible toteach alcoholics to resist the temptation to drinkin these situations. The main technique used inthis teaching exercise is assigning homework andallowing the alcoholic to gradually experiencemore difficult assignments while not drinking.Homework assignments involve going into situa-tions previously associated with drinking andpracticing alternative behaviors. The homeworkassignments are individualized to increase the rel-evance for specific clients. It is hypothesized thatrepeated exposure to these high-risk settings with-out the use of alcohol will increase feelings of288
Relapse Prevention ModelsTABLE 2. Wallace’s Relapse Prevention ModelDrug: Crack CocaineFormat: Materials to be used in inpatient, outpatient, and TC settings, in group or individual sessions.Duration: OpenContent: Psycho-educational approach employing the use of metaphor to illustrate important issues in crack recovery.The principles and the illustrations of those principles are derived from psychodynamic and cognitive-behavioral theory. The topics include: discussions about ways to identify, label and manage emotions;dysfunctional families; self-esteem; self-image; workaholism; use of twelve-step programs; triggers; cravings.competence and self-efficacy. These positive feel-ings will reinforce the maintenance of alcoholabstinence. The Annis model is presented in Ta-ble 3.Annis has conducted evaluations of these treat-ment protocols in several studies. In an open trialwith 41 alcoholics, it was demonstrated that cli-ents would participate in these sessions (over 80%attendance) and that they would complete home-work assignments (80% completion). Measuresof alcohol consumption: drinking during treat-ment; 3 months posttreatment; and 6 months post-treatment drinking all indicated very substantialreductions from baseline. 47% reported total ab-stinence at 3 months and 29% reported total absti-nence at 6 months posttreatment (Annis &Davis, 1988).In a controlled trial using random assignment,alcoholic subjects were assigned to either the An-nis RP model or to a traditional counseling proto-col. There were no differences found betweengroups at 6 month follow-up. However, there wasa significant reduction of alcohol consumption bya specific subgroup of alcoholics who receivedthe RP method. Those clients whose drinking hadbeen associated with a specific set of situationsor conditions benefited more from the RP programthan from the traditional counseling program. Forthose clients whose drinking was more general-ized to a wide range of settings, the RP approachdid not demonstrate superiority (Annis, 1990).This latter finding has led Annis to hypothesizethat RP procedures may be useful with a specifictype of alcoholic but are not necessarily a superiortreatment for all alcoholics. This hypothesis isconsistent with the results of a study by Ito, Dono-van & Hill (1988). This study reported that therewas no significant difference in drinking outcomewith alcoholics who received a RP-oriented after-care group as compared to an aftercare groupusing process-oriented group therapy.In summary, the status of specific RP protocolsfor the treatment of alcoholism does not supportthe use of these methods as stand alone treatmentfor heterogenous groups of alcoholics. Additionalresearch is needed to identify subgroups of clientswho respond positively to this approach. It ispossible that RP techniques should be used withina comprehensive treatment model for alcoholismin order to maximize their therapeutic benefit.Relapse Prevention Treatment for MarijuanaDependence—Roffman and AssociatesRoffman & Bemhart (1987) conducted ananonymous telephone survey to determine if therewas a substantial group of people who were inter-TABLE 3. Annis Alcoholism ModelDrug: AlcoholFormat: Six-hour assessment (individual discussion and questionnaire). Eight 90-minute outpatient sessions. Consistingof one hour of group and thirty minutes of individual counseling.Duration: 12 weeksContent: Assessment period collects data from subjects about drinking behavior and educates subject about high-riskdrinking situations. Treatment period uses group session to discuss problem-drinking situations, constructhomework assignments and review progress on homework assignments. Subjects are given a number ofassignments over 3-month period (about 3-5 per week). Homework assignments involve: planning andimplementing alternative coping responses in high-risk situations; increasing alternative activities to drinking(e.g., leisure activities); improving interpersonal competency; increasing social interactions; testing personalcontrol; and attempting to resolve relationship problems. The model attempts to give subjects increasingamounts of control over the type of homework assignments chosen to increase internal attribution for success.289
R. A. Rawson et al.TABLE 4. Roffman’s Model for Treatment of Marijuana DependenceDrug: MarijuanaFormat: Two group orientation and assessment meetings. Treatment sessions 2 hours long; 8 weekly sessions, 2 bi-weekly sessions.Duration: 12 weeksContent: Subjects are taught to analyze the situations aad antecedent conditions for their marijuana use. Discussionsof craving and patterns of use help clarify high-risk situations. Alternative coping skills are selected and role-played. Self-talk exercises are employed to counteract negative cognitions and slip episodes are refrained tocounteract unproductive negative attributions. Planning sessions are employed to deal with upcoming high-risk situations. Relaxation training, behavioral rehearsal to recruit social support, and homework assignmentsto instigate life-style change are also included.ested in receiving treatment for marijuana depen-dence. The results of their survey suggested thatin their geographic area (Seattle) there was con-siderable interest in treatment for marijuana de-pendence and when treatment was made availablethere was a rapid recruitment of subjects. Thetreatment that was constructed for this group usedan RP model which adapted material from Marlatt& Gordon (1985) for the specific needs of mari-juana users. The treatment model was deliveredin a group format consisting of 10 sessions whichwere scheduled over a 12-week period. An out-line of the model is presented in Table 4.This treatment model has been evaluated in acontrolled study comparing subjects receiving theRP model with a group receiving a social supportprocedure (Roffman et al., 1990). The results ofthe study suggested that the RP procedure pro-duced a greater reduction of marijuana use thandid the social support procedure. Table 5 illus-trates that at one-month follow-up, subjects in theRP group had used marijuana on fewer days dur-ing the preceding month and had fewer total epi-sodes of use in the previous 30 days. There was,however, no significant difference in the numberof subjects abstinent from marijuana over the 30-TABLE 5. Relapse Prevention for Marijuana AbuseSelf-reported Marijuana Use at One Month Post-treatmentNumber of days of use in pastmonth*Weekly frequency of use*% totally abstinent**RelapsePrevention(n = 45)8.23.736%SocialSupport(N = 52)13.05.525%* P < .0001** P > .05day follow-up period. Also, since the follow-upperiod was only 30 days, it would be of interestto know if the group difference was significant at6 or 12 months followup.Other findings from this study suggested thatRP group subjects rated their treatment experi-ence more positively than the social support groupsubjects and the RP group subjects reported usingtreatment information more often than social sup-port group subjects. Subject reports from bothtreatment conditions indicated that the cessationof marijuana use had very significant beneficialeffects on their functioning.The protocol and treatment materials createdby Roffman and associates provide an excellentframework for an outpatient treatment approachfor marijuana dependence. The specificity of thematerials to the issues experienced by marijuanausers gives the treatment approach great credibil-ity with clients. Client retention is greatly en-hanced by the relevance of the information.Relapse Prevention for Cocaine Abuse—Carrolland AssociatesDuring the 1980s, RP strategies were quicklyadapted for the treatment of cocaine abuse (Raw-son et al., 1986, 1990; Washton, 1987, 1989;Wallace, 1988, 1990, 1991). The group at Yalealso provided clinical guidelines regarding thevalue of RP techniques for the treatment of co-caine abusers (Carroll, Rounsaville, & Keller,1991). In addition, the group conducted the firstwell-controlled evaluation of a RP protocol forthe treatment of cocaine abuse. Table 6 providesa brief overview of the protocol format andcontents.A study evaluating this protocol involved therandom assignment of 42 subjects to either an RPcondition or a similar amount of contact with atherapist using an interpersonal psychotherapy290
Relapse Prevention ModelsTABLE 6. Carroll’s Model of Relapse Prevention of Cocaine AbuseDrug CocaineFormat: Individual SO-minute therapy sessions once per week.Duration: 12 weeksContent: In individual sessions the subject is taught to recognize his/her own high-risk situations and develop newresponses to these situations. In addition, the client is taught about the process of craving and is given urge-control strategies. The content is individualized to address the specific issues encountered by clients. Thereis a strong psychoeducational component to the approach, although the education is presented within thecontext of a psychotherapeutic relationship.approach (IPT) (Carroll, Rounsaville & Gawin,1991). Table 7 presents a summary of some ofthe main findings.As Table 7 indicates, there were a number ofindicators which suggested that the RP approachappeared somewhat superior to the IPT approachbut, due to the relatively small sample size, thegroup differences did not achieve statistical sig-nificance. Two-thirds of the RP group were re-tained for the 12-week protocol. During thecourse of treatment there was a very substantialdecrease in cocaine use for subjects in bothgroups. Comparisons of ASI scale scores sug-gested a significant improvement in social func-tioning on all 7 ASI subscales with the psycho-logic functioning scale indicating superiority ofthe RP group. Of significant interest is the findingthat with a subsample of severely addicted co-caine users, the RP approach did result in a sig-nificantly more positive treatment outcome ontwo measures of abstinence at follow-up.The combined data from this study suggest thatthe RP protocol provided substantial clinical ben-efit for cocaine abusers. The methodology usedin the study protocol involved a well-constructedformat with exceptionally well-designed controlsto ensure protocol compliance. Treatment reten-tion and analysis of outcome by severity of druguse and psychiatric severity measures, along withthe ASI, provide an evaluation methodologywhich could be widely used for future researchon RP models.Recovery Training and Self-HelpModel—McAuliffe and AssociatesMcAuliffe and associates have constructed anintensive outpatient treatment model combiningRP strategies with self-help concepts. (McAu-liffe, 1990; McAuliffe & Ch’ien, 1986; Zackon,McAuliffe & Ch’ien, 1985). The model has beenused primarily as an outpatient aftercare strategyfor the treatment of opioid users in New Englandand Hong Kong. A manual has been constructedwhich lays out the treatment exercises in detailto allow for replication and evaluation. The treat-ment model contains a set of training materialsadapted from the work of Marlatt & Gordon(1985). In addition, clients are encouraged to de-velop group cohesivenss through involvement ina self-help component. This self-help componentis not related to the twelve-step program of Alco-holics Anonymous, but does promote a sense ofTABLE 7. Relapse Prevention for Cocaine Abuse% with 3 consecutive weeks abstinent*% “recovered”*% completed 12 weeks treatment protocol*% with 3 consecutive weeks abstinent**% “‘recovered”*** P > .05** P < .05 for both comparisonsTotal SampleRelapse Prevention(n = 21)57%43%67%Severe Users54%54%•Interpersonal Psychotherapy(AT = 21)33%19%38%9%0%291 R. A. Rawson et al.TABLE 8. McAuliffe's Recovery Training & Self-Help ModelDrug: Opioids (subjects detoxified from illicit opiates or methadone).Format: One recovery training group and one self-help group per week. Each group session is 90 minutes. Additionalweekend activities to create addict support network.Duration: 6-month minimum, optional additional 6 months.Content: Four Components1. Recovery Group—26 sessions led by professional therapist. Provides information and discussion aboutcraving, triggers, high-risk indicators, alternative coping skills, drug-using friends, stress management,extinction of conditioned craving, increasing leisure activities, relationship issues.2. Self-help Group—26-session peer-led group to address problems and crises that are encountered ineveryday functioning. Formal group structure, rules, policies are used to plan recreational activities,confront members resistance, reinforce positive changes and create a peer atmosphere. Not twelve-steporiented.3. Recreational and Social Activities—weekend and holiday social activities including; picnics, trips tomuseums, baseball games, talks at high schools, camping trips, etc.4. Senior Network—Use of program graduates in self-help meetings and activities as role models and supportsystem for newer members.addicts helping each other which is common to allself-help approaches. This self-help componentprovides a forum which allows clients to planand structure leisure and recreational activitiestogether, expanding their non-drug using behav-ioral repertoire. Within this component, there isalso the opportunity for senior members of theprogram to gain self-esteem by serving as rolemodels for new members. A summary of themodel is presented in Table 8.The RTSH model has been evaluated in a largecontrolled trial with random assignment. In thisstudy 168 subjects were randomly assigned toeither the RTSH program or a control conditionwhich consisted of referral to another community-based aftercare program. All subjects were opioidaddicts who had recently been detoxified fromillicit opioids or from methadone treatment. Thisstudy, therefore, evaluated the RTSH model asan outpatient aftercare strategy and not as a stand-alone outpatient treatment approach. The resultsof the study were extremely promising. Table 9presents several of the central findings.As presented in Table 9, subjects in the RTSHprogram showed superior levels of opioid absti-nence at 6- and 12-month follow-up points. Inaddition, subjects in the RTSH group demon-strated significantly more employment activityand less criminal activity during the 12-monthfollow-up point. Ratings of satisfaction by clientssuggested that the RTSH group found their treat-ment experience more helpful than the controlsubjects found theirs, and the mean retention rateof 4 months by RTSH subjects suggests that theprogram was able to sustain the treatment involve-ment of this group.It should be noted that although the RTSH ap-proach demonstrated significantly better outcomeon important clinical measures, the abstinencerate at 12 months was only 30%. This findingunderscores the difficulty of treating opioid userswith non-pharmacologic and non-residentialtreatment approaches. It is possible that the out-come with this model could be improved by com-bining the approach with a pharmacologic treat-ment such as naltrexone. Similarly, it is possiblethat the use of this model with other categories ofdrug users such as cocaine abusers or alcoholicsmight show higher rates of follow-up abstinence.The RTSH model is the first attempt to builda structured outpatient treatment program aroundRP concepts and strategies. The development ofa formal treatment manual and the controlledevaluation of this model are extremely importantTABLE 9. Relapse Prevention for Opioid AbuseRTSH Group*(n = 93)Control Group(n = 85)% abstinent at 6 months 34%% abstinent at 12 months 30%20%**15%*** RTSH group demonstrated an increase in employment andreduction in crime at 12-month follow-up.** P < .05292 Relapse Prevention Modelssteps in systematically implementing RP proce-dures into the mainstream treatment system. Fur-ther refinement of the RTSH model for differentpopulations will strongly influence the continuingdevelopment of viable outpatient addiction treat-ment.Washton's Intensive Outpatient ModelWashton and Stone-Washton have incorpo-rated RP materials into a structured treatmentmodel which is being used with a broad range ofdrug and alcohol users in a commercial treatmentcenter in New York City. Washton's model, ini-tially developed with cocaine abusers, providesa stand-alone outpatient treatment program foraddicts and alcoholics. It can also be used as anaftercare program following inpatient and outpa-tient detoxification. His clinical perspectives ontreatment issues with cocaine abusers have beendocumented in several books (Washton 1989;Washton & Gold, 1986). His RP exercises havebeen structured into several workbooks which areused by patients during the course of treatment(Washton, 1990, 1991).The format of the program includes 3 weeklygroup sessions for 4-6 months. The intensiveuse of group methods results in the group itselfbecoming a powerful instrument for change.Washton has detailed key group conduct issuesthat facilitate treatment retention and behaviorchange (Washton, 1989). Strategies for engagingclients in treatment have also been developed toaddress client resistance and to discourage "tradi-tional" confrontational methods of addictioncounseling. Washton has adapted the work of Pro-chaska & DiClemente (1986) on stages of changefor use in clinical treatment planning. Under-standing that addicts and alcoholics enter treat-ment at different stages in the addiction processcan reduce therapist frustration with "unmoti-vated clients." With this change of perspective,therapists are able to create a treatment atmo-sphere where clients can change at their ownpace. Washton has addressed this aspect of histreatment approach in a recent publication (Wash-ton & Stone-Washton, 1991). Concurrent involve-ment in twelve-step activities is strongly encour-aged as part of the recovery plan. Frequent urinetesting is emphasized as an essential part of theoutpatient model. Table 10 presents an overviewof the elements of the Washton treatment model.At the present time, there has been little sys-tematic evaluation of the Washton model. Table11 presents some outcome data from an open trialof this model with cocaine users. In this trial,outcome of 60 clients who entered outpatienttreatment directly was compared with a group of20 clients who entered this program after inpatienthospitalization.Retention rates and abstinence rates at follow-up were comparable for the two groups suggestingthe viability of the treatment approach as a stand-alone treatment experience. Overall, across bothgroups, it was noted that 31% of the cocaineabusers had been abstinent during the entire 6-24month treatment and follow-up period.TABLE 10. Washton's Intensive Outpatient ModelDrug: Cocaine (also with alcoholics and detoxified opiate users)Format: Three therapy group sessions per week for 4-6 months. One education group per week for 12 weeks.Individual sessions scheduled on an individualized basis. Weekly support groups months 7-12. Twice weeklyurine testing for 6 months.Duration: 12 monthsContent: 1. Initial period for obtaining abstinence—Topics include: identifying cocaine cues; eliminatingparaphernalia; avoiding users; avoiding high risk places, saying no!; discussing cravings; handling "slips."2. Preventing relapse—Topics include: how to define a relapse; relapse patterns; antecedents to relapse;negative attitudes; overconfidence; euphoric recall; desire to test control; sexual problems; relapse behaviors;impulsive and compulsive behavior; handling relapses.3. Strategies developed which promote retention of clients in treatment. Therapists are trained to considerthe point of view of the client in the development of treatment planning and program expectations. Clientsare not all expected to begin treatment with the same commitment to recovery or willingness to change.This outlook on the treatment process reduces the confrontational flavor of treatment and encourages aview which reinforces positive change at an individualized rate.4. Involvement in twelve-step activity is strongly encouraged.5. Frequent, supervised urine tests.293 R. A. Rawson et al.TABLE 11. Relapse Prevention for Cocaine AbuseOutpatient Only(n = 60)Inpatient plus Outpatient(n = 20)% completing treatment 74%% abstinent for 30 days at follow-up (6-24 months) 68%% abstinent for entire follow-up period77%64%31%Washton's model has now been used in a pri-vate outpatient setting for over 5 years. It hasgained acceptance by insurance companies andemployee assistance programs as a treatment re-source in the New York City area. This model andthe following model by Rawson and associatesare the first intensive outpatient treatment modelsemphasizing relapse prevention strategies to beaccepted in the mainstream commercial treatmentsystem. This development is significant becauseit signals the emergence of commercially viabletreatment models based on empirical principlesrather than a philosophical bias. The creation oftreatment models specifically designed for outpa-tient implementation, rather than outpatient mod-els adapted inappropriately from inpatient set-tings, is a promising development in the privatetreatment sector. Hopefully, additional empiricalsupport will be forthcoming on the Washton treat-ment model to provide a clearer understanding ofthe applicability of this method.The Matrix Neurobehavioral Model—Rawsonand AssociatesAs the cocaine epidemic accelerated in theearly 1980s, cocaine users began to seek treat-ment in large numbers. In 1983 the Matrix Centerwas established in Southern California to providethese people with a structured outpatient treat-ment experience. The program was designedaround cognitive behavioral principles with manyof the RP techniques previously described. Themodel was given the name neurobehavioral sinceit was hypothesized that stimulant addicts experi-ence a biological recovery from chronic stimulantabuse that results in clear stages of recovery(Rawson, 1990, 1991; Rawson et al., 1990,1991).These stages result from the neurochemical andneurophysiological normalization which occursupon cessation of stimulant use. The stages areaccompanied by a predictable series of affective,cognitive and behavioral changes. The treatmentmaterials which have been developed for the Ma-trix neurobehavioral model are sequenced to ad-dress the clinical issues in the order that theytypically emerge.The treatment model provides intensive treat-ment contact over the initial 6 months. Alongwith the cognitive-behavioral emphasis, there isa significant amount of family participation ineducational sessions and conjoint sessions. Urinetesting is an integral part of the program andinvolvement in 12-step programs is encouraged.The program format and content is presented inTable 12.The Matrix neurobehavioral treatment modelhas been formalized into a 300-page treatmentmanual (Rawson et al., 1989). This standardiza-tion of the model has allowed for replication andevaluation. The evaluation efforts have been acentral element in the creation of the model. Theongoing evaluation of the model and individualtreatment components has provided direction forthe evolution of the treatment approach. An initialpilot study was conducted in 1985 which indi-cated that significantly fewer cocaine abusers whowere treated with the neurobehavioral protocolon an outpatient basis were using cocaine at fol-low-up than those who received treatment in a28-day hospital, or a third group which receivedno treatment. The results of that study, illustratedin Table 13, also confirmed a relationship be-tween the use of both alcohol and marijuana andrelapse to cocaine. In response to this finding thetreatment philosophy of the Matrix model in-cludes a strong recommendation for abstinencefrom alcohol and other drugs in the cocaine recov-ery program.In a more recent study, treatment outcomesfor cocaine users who were treated at 2 differentoffices of the Matrix Center were compared. Thetreatment protocols in both offices were identicaland the treatment was supervised by the sameclinical supervisor. Although individual thera-pists differed in the two clinics, ratings of thera-294 Relapse Prevention ModelsTABLE 12. The Neurobehavioral Model*—Rawson and AssociatesDrug: Cocaine and MethamphetamineFormat: One 45-minute individual session and three 90-minute group sessions per week for 4 months. Three groupsessions a week and two individual sessions for an additional 2 months. One group per week for months7-12. During the first 6 months there are 3 conjoint sessions with patient and family member.Duration: Six-month intensive phase; six months continuing care.Content: Components1. Individual Sessions—Twenty topics sequenced to address emergence of issues in stimulant recovery.Topics include: triggers, dealing with craving; leisure activities; time management; following recoveryplan; coping with emotions; drug using friends; lifestyle change; neurochemistry of cocaine withdrawal.In addition, there are 3 conjoint sessions with family members to integrate the program withrelationship changes.2. Family Educational Group—Sixteen topics including: addiction and the brain; drug use and AIDS;relationships and addiction; stimulant effects; types of treatment; introduction to twelve-step program.3. RP Group—Forty-eight topics including: addict behavior; relapse justification; relapse and fatigue; relapseand holidays; secondary drug use; leisure activities; sex and recovery; emotional building; holidays andrelapse.4. Social Support Group—Continuing care support group.5. Twelve-step Involvement—Weekly attendance at twelve-step meetings is encouraged.6. Relapse Analysis—A structured relapse analysis exercise is used to clearly outline the antecedents to arelapse episode and to reframe the episode in order to avoid an abstinence violation effect.7. Urine Testing—Weekly urine tests are used to monitor progress and provide feedback.pist effectiveness in the two clinics were compara-ble. The major difference in the two populationswas social status, educational level and employ-ment level. In one clinic, the clients were predom-inantly middle class, college educated and em-ployed. In the other clinic, a majority of theclients were low income, high school educatedand unemployed. In the middle class clinic, cli-ents self-paid for treatment or used private insur-ance. In the lower income clinic, treatment wassubsidized by the local health department and asmall co-payment. Drug use histories, route ofTABLE 13. Relapse Prevention for Cocaine AbuseOutpatient(n = 30)% returning to monthlycocaine use at 8 monthfollow-up 13%Monthly alcohol useNo alcohol useMonthly marijuana useNo marijuana useAA/CAHospital Meetings(n = 23) (n = 30)43% 47%% Relapse to Cocaine(n = 83)50%6%59%20%administration, and amount of drug use at admis-sion were similar for both groups.Some results of this study are summarized inTable 14. The retention rate and 6-month drug usestatus of the clients treated in the private treatmentclinic were significantly better than in the lowincome clinic. During the period of treatmentinvolvement, however, drug use was virtually atthe same level in both clinics. The results suggestthat this Matrix treatment model was extremelyuseful with the middle class clients but the lowerincome subjects experienced poorer treatmentoutcome. It is certainly possible that this disparitymay be true for all modalities of substance abusetreatment. However, it is increasingly clear, asthis model is utilized with a higher proportionof indigent, underemployed, less-educated crackabusers, that the retention rates and follow-upabstinence rates have decreased.The Matrix treatment model is currently receiv-ing extensive evaluation. Outcome studies are un-der way comparing this model to inpatient hospi-tal treatment and no treatment. A controlledevaluation with random assignment is near com-pletion comparing the neurobehavioral modelwith referral to other community programs. In astudy designed to evaluate the value of desipra-mine in combination with an intensive outpatient295 R. A. Rawson et al.TABLE 14. Relapse Prevention for Cocaine AbuseMiddle Class Private Pay Subjects Lower Income County Funded Subjects(n = 314) (n = 172)Mean weeks in treatment% cocaine-free for 30 days at 6 months% negative urine samples at 6 months21.086%88%13.2*58%*88%* P < .01psychosocial protocol, the Matrix model is theprotocol being employed. A modified version ofthe model is being tested with cocaine-abusingmethadone patients and with cocaine-abusingwomen with children. Recently, the state ofTexas has contracted with a community agencyto test the model in a program for crack users inHouston. While this extensive testing is underway, the model is being employed with the pri-vate treatment clients at the Matrix Center in fourclinics in the Los Angeles area. This model hasbeen accepted in the community as a viable outpa-tient approach for the treatment of stimulantabuse. The Washton model and the Matrix modelare the first intensive outpatient treatment modelsbased upon RP principles to be employed in thecommercial treatment system. With this approachestablished as an accepted treatment modality,empirically-based outcome data from current re-search projects will be used to further refine thetreatment. Developing and delivering this typeof substance abuse treatment in both public andprivate treatment settings is a step forward in thesystematization of outpatient chemical depen-dency treatment. RP strategies and cognitive-be-havioral techniques have played a critical role inthe development of these treatment approaches.The Role of Relapse Prevention Modelsin Substance Abuse TreatmentDuring the past ten years the RP concept hasbecome generally accepted within the field of ad-diction. A recent issue of the Journal ofPsychoac-tive Drugs, edited by Joan Zweben (April-June,1990) presents an excellent collection of articleson the use of RP techniques for a broad range ofsubstance abuse disorders. RP strategies havebeen adapted for use in multiple clinical settings.Table 15 lists some of the settings in which RPstrategies have been employed.The RP approach provides a conceptually con-sistent framework for the delivery of a nonphar-macologic outpatient treatment model. It providesaddicts/alcoholics with a set of tools and informa-tion that better equips them to understand theprocess of relapse. The techniques directly ad-dress factors which have been identified by clientsas being problematic in maintaining abstinencefrom drugs and alcohol. In addition, the RP ap-proach acknowledges the problem of relapse andpresents the addict and the clinician with a frame-work for preventing minor "lapses" and "slips"from becoming major relapses leading to readdic-tion. The use of these strategies does not presumeunderlying causal mechanisms of addiction;rather, RP techniques directly address the drugusing behavior. They provide clinicians with aset of interventions which are helpful in promot-ing the acquisition of responses which are incom-patible with substance abuse disorders.Clearly, the development and refinement of theRP approach was the major nonpharmacologicsubstance abuse treatment advancement in the1980s. It is unclear at this time how extensivelythese techniques will be adapted. The enthusiasmfor the use of the techniques is quite high. How-ever, the evaluations of specific protocols andintegrated models are at an early stage of develop-ment. Continued empirical testing of these tech-niques and models is essential to the developmentTABLE 15. Settings/Populations for Relapse PreventionImplementationOutpatient Addiction/Alcoholism ClinicsInpatient Hospital UnitsAftercare Programs for Inpatient ProgramsTherapeutic CommunitiesDUI ProgramsWorkplace EAP ProgramsAdolescent Substance Abuse ProgramsCouples Therapy Programs for AddictsHealth Care Professionals Treatment ProgramTreatment Framework for Pharmacologic EvaluationsInner-City Clinic for Crack-Smoking MothersCocaine-Abusing Methadone Patients296 Relapse Prevention Modelsof this approach. Since the techniques are clearlydefinable and replicable, the systematic evalua-tion of the approach is very feasible. Use of treat-ment manuals which standardize protocols forreplication and evaluation has improved re-search methodology.It appears likely that for some disorders, suchas cocaine dependence, outpatient models builtaround RP techniques may provide a substantialgroup of addicts with viable treatment. For othertypes of clients, including alcoholics, RP modelsmay apply for an identifiable client subset. Forstill other populations, including opiate addicts,RP strategies may be useful as aftercare but areapparently not sufficient with acutely addictedclients.RP techniques are communicated to clients ver-bally and in writing. Clients must be capable ofprocessing information and using cognitive tech-niques. The techniques have limited usefulnesswith clients who do not have the capacity or edu-cation to understand or use the treatment materi-als. Clinical experience by the authors with thisapproach suggests that the specific treatment exer-cises need to be tailored to the needs of differentpopulations. The treatment exercises used withstable, middle class, well-educated, employed,intranasal cocaine users are quite different thanthe exercises which are appropriate for inner-citycrack smokers. Specific techniques chosen mustallow for the client's capabilities and the environ-ment within which the client is living. RP tech-niques can be translated to a wide range of popula-tions with appropriate construction of relevantconcepts. Specific cultural and gender issues mustbe sensitively addressed. However, if these issuesare accommodated, it does appear that the RPapproach can be adapted successfully for a sub-stantial range of substance abuse.The context in which relapse prevention strate-gies are used is likely to effect the specific typesof procedures used and the impact of these proce-dures. For example, relapse can be a frequentoccurrence during the treatment process of an out-patient episode. Therefore, relapse preventionstrategies used in this setting must include proce-dures for actively addressing this issue as part ofthe course of treatment. In residential settings,however, relapse is a much less common occur-rence. Consequently, the discussion of relapseduring treatment may have a very different sig-nificance and a different response to relapse inthis setting may be required.A potentially valuable role for the use of RPmodels is to provide a psychosocial frameworkwithin which pharmacotherapies can be evalu-ated. Annis (1990) has evaluated RP strategieswith alcoholics in conjunction with the alcoholsensitizing medication, calcium carbamide. Raw-son and colleagues are currently conducting eval-uations of several medications for cocaine depen-dence in a treatment context in which all subjectsare receiving treatment with the neurobehavioralmodel. Similarly, the same investigators are de-veloping a manual based upon RP techniques tofacilitate the use of naltrexone with detoxifiedopiate users. The value of RP strategies in combi-nation with medications has not been empiricallyestablished, however due to their standardizationand replicability they appear to provide an excel-lent protocol for this purpose. Also, since thetechniques are flexible and modifiable to specificpopulations and settings, the protocols can be tai-lored to complement the pharmacologic proper-ties of the medications. For example, since medi-cation compliance is problematic when usingnaltrexone in opiate addiction treatment, RP tech-niques will address the discontinuation of medica-tion-taking as an important pre-relapse indicatorof return to opiate use.SummaryRP techniques have received much attentionduring the last ten years. 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ReviewCraving’splaceinaddictiontheory:ContributionsofthemajormodelsMarilynD.Skinnera,1,*,Henri-JeanAubinb,1aCentredeTraitementdesAddictions,CentreHospitalierEmileRoux,1avenuedeVerdun,94456Limeil-Bre´vannes,FrancebCentreHospitalierUniversitairePaulBrousse,12avenuePaulVaillantCouturier,94800Villejuif,FranceContents1.Cravingasaterm.................................................................................................6072.Theoriesofcraving...............................................................................................6082.1.Conditioning-basedmodels...................................................................................6082.1.1.Withdrawalmodel...................................................................................6082.1.2.Compensatoryresponsemodel.........................................................................6082.1.3.Opponent-processmodel.............................................................................6092.1.4.Incentivemodel.....................................................................................6092.2.Cognitivemodels...........................................................................................6102.2.1.Outcomeexpectancymodel...........................................................................6102.2.2.Dual-affectmodel...................................................................................6102.2.3.Affectiveprocessingmodelofnegativereinforcement......................................................6112.2.4.Cognitiveprocessingmodel...........................................................................6112.3.Psychobiologicalmodels......................................................................................6122.3.1.Three-pathwaypsychobiologicalmodel..................................................................6122.3.2.Incentivesensitizationmodel..........................................................................6142.3.3.Theoryofneuralopponentmotivation...................................................................6152.3.4.Temporal-differencereinforcementlearningmodel........................................................6152.3.5.Uniﬁedframeworkforaddictionmodel..................................................................6152.3.6.Neuroanatomicalmodel..............................................................................6162.3.7.Modelofinteroceptivedysregulation....................................................................6162.4.Findingsfromneuroimagingstudiesandcraving..................................................................6172.5.Motivationalmodels.........................................................................................6182.5.1.Motivationalmodelofalcoholuse......................................................................6182.5.2.Multidimensionalambivalencemodel...................................................................6182.5.3.Primetheory.......................................................................................619NeuroscienceandBiobehavioralReviews34(2010)606–623ARTICLEINFOArticlehistory:Received28August2009Receivedinrevisedform25November2009Accepted26November2009Keywords:CravingUrgeModelAddictionAlcoholDrugABSTRACTWeexamineinthispapertheunfoldingofcravingconceptswithin18modelsthatspanroughly60years(1948–2009).Theamassedevidencesuggeststhatcravingisanindispensableconstruct,usefulasaresearchareabecauseithascontinuedtodestabilizepatientsseekingtreatmentforsubstances.Themodelsfallintofourcategories:theconditioning-basedmodels,thecognitivemodels,thepsychobiologicalmodels,andthemotivationmodels.Intheconditioningmodels,cravingisassumedtobeanautomatic,unconsciousreactiontoastimulus.Inthecognitivemodels,cravingarisesfromtheoperationofinformationprocessingsystems.Inthepsychobiologicalmodels,cravingcanbeexplainedatleastinpartbybiologicalfactorswithanemphasisonmotivationalcomponents.Finally,inthemotivationmodels,cravingisviewedasacomponentofalargerdecision-makingframework.Itiswellacceptedthatnosinglemodelexplainscravingcompletely,suggestingthatasolidunderstandingofthephenomenonwillonlyoccurwithconsiderationfrommultipleangles.Areformulateddeﬁnitionofcravingisproposed.2009ElsevierLtd.Allrightsreserved.*Correspondingauthorat:CentredeTraitementdesAddictions,CentreHospitalierEmileRoux,1avenuedeVerdun,94456Limeil-Bre´vannes,France.E-mailaddress:marilyn.skinner@erx.aphp.fr(M.D.Skinner).1AssistancePublique-HoˆpitauxdeParis,INSERMUnite´U669,Paris,France.ContentslistsavailableatScienceDirectNeuroscienceandBiobehavioralReviewsjournalhomepage:www.elsevier.com/locate/neubiorev0149-7634/$–seefrontmatter2009ElsevierLtd.Allrightsreserved.doi:10.1016/j.neubiorev.2009.11.024 3.Summaryandconclusions..........................................................................................620Acknowledgements...............................................................................................621References......................................................................................................621Therehasbeenmuchcontroversyoverthelastseveraldecadesabouthowtodeﬁnecraving.Consideredbysometobeattheheartofaddictionandthereasonwhyrelapseissofrequent,thesubjecthasinspiredavastliteratureresultingindiversetheoreticalpositions.Herewewillprovideabriefhistoricalreviewoftheuseoftheterm‘‘craving’’,oritsfrequentlyusedsynonym‘‘urge’’,andthenreview18oftheprincipaltheoriesormodelsinwhichcravingiseitherthecentralfocusoramajorcomponentofalargeraddictiontheory.Ourobjectiveistoreviewtheprogressionofthoughtregardingthedesiretoconsumefrommultipleanglesbydiscussingthemostinﬂuentialmodelstodate.Strengthsandshortcomingsofthemodelswillbediscussedwhereappropriate.Simplystated,wewishtoanswerthequestions:Whatcausescraving,andhowisitmanifestedinwhatcontextandaccordingtowhom?Todatethereisnoonerightmodel.Perhapsthereisanongoingdebatebecausethereissomethingofvalueinallofthemodels.Manymodelspresentedherefocusonnarrowbasicassumptionsandtendtofallshortofacompleteexplanationbecausetheycannotbeappliedwidely.Wewillalsopresentanattemptatintegratingthediversetheoreticalpositionsintwoofthemodels.Therehasbeenmuchconfusioninthisdomain,complicatedfurtherbecausetheoriesofcraving,theoriesofaddiction,andtheoriesofmotivationoftenoverlap.Itisusefultobeginbylookingathowtheuseofthetermhasevolvedsincethe1950sbeforeexaminingthekeytheoreticalpositions.1.CravingasatermDuringameetingin1954convenedspeciﬁcallytoclarifytheuseofthetermcraving,theWorldHealthOrganization(WHOExpertCommitteesonMentalHealthandonAlcohol,1955)concludedthatasatechnicalterminresearchonalcoholuse,thetermcravingwasconfusingandinappropriatebecauseofitseverydayconnotationsasan‘‘urgentandoverpoweringdesire’’.Asaresult,twomorepreciseformulationswereproposedtoreplacethetermcraving:(1)‘‘physicaldependence’’asasubstitutefor‘‘physicalcraving’’referringtowithdrawalsymptoms,and(2)‘‘pathologicaldesire’’asasubstitutefor‘‘symboliccraving’’,encompassingallaspectsofcravingintheabstinencephaseoncethewithdrawalsymptomshavedisappeared.The‘‘pathologicaldesire’’wasthoughttoberesponsiblefortheinitiationofexcessivealcoholintakeandforrelapse(WHOExpertCommitteesonMentalHealthandonAlcohol,1955;KozlowskiandWilkinson,1987).InspiteoftheWHOpanel’sadvice,thetermcravingpersisted,notablyphysicalcravingwhichbecamecloselyassociatedwiththemedicalmodelofalcoholismwhilethepsychologicalaspectswerelargelyignored(Rankinetal.,1979).Themedicalmodelbasicallyeliminatedtheelementofchoiceinthematterofaddiction.Theaddictwasviewedaspossessedbyanall-encompassingdesirethatwascausedbyphysiologicalchangesbroughtaboutbythediseaseofaddiction.In1960,Jellinek(1960),oneoftheexpertsonthe1954WHOpanel,disregardedthesummarystatementofthecommitteeandrevivedthetermcravingwhenhepublishedTheDiseaseConceptofAlcoholism(KozlowskiandWilkinson,1987).Becauseitwasregardedastheunderlyingbasisfortheonsetofaddiction,relapse,excessivedrinking,andthelossofcontrolbytheWHOpanel,cravingwasconsideredakeysymptomofalcoholismandenteredintotheInternationalClassiﬁcationofDiseases(ICD).ItremainsoneofthediagnosticcriteriaintheICD-10(WorldHealthOrganisation,1992),althoughitdoesnotfeatureintheDSMIV(AmericanPsychiatricAssociation,1994;Drummond,2001).Whenthemedicalmodelwaschallengedbynewbehavioralapproachesthatemphasizedobservableandveriﬁablebehavioraswellasmeasurableinternalevents(e.g.,theSkinnerianoperantconditioningmodel),theconceptofcravingasaphysicaldependencewasagainthreatened(Rankinetal.,1979).Rankinetal.reevaluatedandenlargedthemeaningofcravingtorefertoageneric‘‘dispositiontodrink’’,comprisingalllevelsofdesire.KozlowskiandWilkinson(1987)havecriticizedthisbroaddeﬁnitionasadeformationbecauseofthestrongconnotationsalreadyassociatedwithcravingincommonlanguage.Toavoidmisunderstandings,theyarguedinfavorofconservingthetermcravingtodescribeanurgentdesire,statingthatcallingcraving‘‘adispositiontodrink’’waslikecallingterror‘‘fear’’.Viewedfromthisperspective,thedifﬁcultyarisesinchoosingthepointonthecontinuumwherethestrengthofdesireissufﬁcienttobeacraving.West(1987)raisedthispointinsupportofhispositionfavoringusingscalesthatmeasurealllevelsofcraving.Headdedthatthusfar,KozlowskiandWilkinson(1987)haveprovidednoqualitativedistinctiontoidentifydifferentlevels(e.g.,demonstratingthatcertaindrugsortherapiesaffectvariouslevelsofcravingdifferentially).Similarly,Shiffman(1987)objectedtotheideaofdeﬁningcravingasexclusivelyanurgentdesirestatingthatKoslowskiandWilkinsonhadfailedtoprovidesupportiveempiricalevidenceassuch.Withnoconsensusonadeﬁnitionforcraving,someauthorsdismisseditsusefulnessasaterm.Hughes(1987)arguedagainstusingcravingasaconstructbaseduponthelackofagreementastowhatcravingreferstointhecognitiveandthebehavioraldimensions.Othersarguedthattherewastoomuchemphasisfocusedonsemantics,whereaswhatwasessentialweretheimplicationsatatheoreticallevel(Stockwell,1987;West,1987).West(1987)critiquedthequalitativeandquantitativeambiguityofthetermcombinedwiththeabsenceofanyobjectivecriteriatoprovideatechnicaldeﬁnition.Hestated,‘‘Theprocessofformulatingsuchdeﬁnitionsmerelysucksresearchersintounproductiveandunresolvabledisputes’’(p.40).Contrarytotheseviews,Marlatt(1987)supportedmaintainingthetermcravingasaformofpsychologicalattachment.Heproposed,‘‘Cravingisthe‘grasping’qualityofthemindasitattemptstopursueitsattachments’’(p.43).Thisqualityisthoughttobemotivatedbyexternalcues.Forexample,whenanaddicteduserisfacedwithdrugcuestimuli,bothcravingandaversionareprobablyelicited,cravingforthepleasureandaversionfortheunpleasanteffects(Marlatt,1987).Themixedsignalmightsetoffanapproach-avoidanceconﬂict.Marlattdeﬁnedcravingas‘‘thesubjectivedesirefortheeffectsofadrug’’asopposedtourgewhichhedeﬁnedastheintentiontoconsume,whichmayormaynotoccuraftercraving.‘‘Cravingisadesirableterm’’statedMarlatt,‘‘akeyconceptinthepsychologyofattachmentforover2500years’’asdeﬁnedbyEasternschoolssuchasBuddhism(pp.42–43).In1991,ameetingoncravingwasorganizedbytheUSNationalInstituteonDrugAbuse(NIDA).Itwasagainimpossibletoreachaconsensusastothenatureorrelevanceoftheconceptofcraving.Nonetheless,cravingremainstodayofconsiderableinteresttoresearchersdespitetheabsenceoftheoreticalconsensus(MacK-illopandMonti,2007).Itisenjoyinganotablecomebackwithrenewedinterestincuereactivityinrelationtorelapse,M.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623607 pharmacologicaltreatments,andavastarrayofmodulatorsthatareevaluatedbothbyself-reportandautonomicmeasures,includingneuroimaging.2.TheoriesofcravingFromtheearliesttheoriesofmotivationtothelatestﬁndingsfromneuroimaging,thenotionofcravinghasevolvedtoreﬂectmultidimensionalaspectsincludingclassicalconditioning,cogni-tivescience,neuroanatomy/neurotransmittersystemsandpsy-chology.Itisgenerallyacceptedtobecontextdependentandmodulatedbyindividualdifferences.Wepresentherethebasicpremisesoftheprincipaltheoriesofcraving:fourconditioning-basedmodels,fourcognitivemodels,sevenpsychobiologicalmodels,andthreemotivationalmodels.Whenappropriate,theterm‘‘craving’’willbereplacedby‘‘urge’’asonlythistermisusedbycertaintheorists.2.1.Conditioning-basedmodelsTheconditioningmodelsarebasedontheworkoftheRussianphysiologistIvanPavlov(1849–1936)whoformulatedthelearningprocedurecalledclassicalconditioning.Fourmotivationalmodelsofconditioneddrugusedominatedthoughtduringthe1970sand1980s:thewithdrawalmodel,thecompensatoryresponsemodel,theopponent-processmodel,andtheincentiveconditioningmodel(seeTable1).Thoughconsidereddrugusemodels,theyareimportanttocravingtheorybecausetheyassumethaturges(orcravings)areproducedeitherbywithdrawal-relatedprocessesintheﬁrstthreemodelsorbythepromiseofrewardinthelastmodel.2.1.1.WithdrawalmodelThewithdrawalmodelholdsthatindividualsseektoconsumedrugsprimarilyinordertoescapeaversivestates(Wikler,1948).Asopposedtobeingmotivatedbyareward,theseindividualsseektorelievewithdrawal-relateddiscomfort.Themotivationistransformedfromapositivereinforcementtoanegativerein-forcementinSkinnerianterms(Ryckman,1997).Thedesiretousearisesdirectlyfromtheexperienceofwithdrawalandisthusattheoutsetanunconditionedresponsetoalackofdrugs.Itmayalsoarisefromenvironmentalcuesthathavebeenassociatedwithdrugusesuchasdrugparaphernaliawhichhavebecomeconditionedstimuli(Wikler,1980;O’Brienetal.,1981).Althoughithaslongbeenacceptedthatescapingwithdrawalisakeymotivatorofdruguse,anoteworthycontributionofthismodelwasthatwithdrawalcanbeconditionedinthefollowingmanner.Initiallythelackofdrugs(anunconditionedstimulus)provokesawithdrawalsyndrome(anunconditionedresponse).Associatedwiththelackofdrugsareperhapscuessuchasdrugparaphernaliaandnegativeaffectthatthenbecomeconditionedstimulitothewithdrawaldiscomforts.Priortodruguseorduringaperiodofabstinence,thesecuesmayprovokeawithdrawalresponse(aconditionedresponse)thatisthoughttocreateadesiretousethesubstanceinquestion(Bakeretal.,1986).Conditionedwithdrawalhasbeendemonstratedinthelaboratory.Inastudywitheightheroinaddictsmaintainedonmethadone(O’Brienetal.,1977),withdrawalsymptomswereinducedwithnaloxoneandpairedwithatoneandpeppermintfragrance(conditionedstimulus)during12conditioningsessions.Thesesameparticipantswerelaterexposedtotheconditionedstimulus.Clearsymptomsofopiatewithdrawalweremeasurable:decreasedskintemperature,increasedheartrate,andincreasedrespiration.Drummondetal.(1990)expandedthewithdrawalmodelandproposedhowalcoholicscometoexperiencecravingasapartofthewithdrawalsyndrome.Afteraneveningofheavydrinking,thesightandsmellofadrink(theconditionedstimulus)isrepeatedlyassociatedwithwithdrawalsymptomssuchasfallingbloodalcohollevels(unconditionedresponse).Duringaperiodofabstinenceandoncefreeofwithdrawalsymptoms,analcoholcueislikelytoprovoketheconditionedresponseofwithdrawalalongwithconditionedcravingasitisconsideredapartofthewithdrawalresponse.Adecadelater,Drummond(2000)distinguishedtwosourcesofcraving:‘‘cue-elicitedcraving’’and‘‘withdrawal-relatedcraving’’.Hedeﬁnedcue-elicitedcravingasaconditionedresponsetoacue,whereaswithdrawal-relatedcravingreferredtocravingthattookplaceduringthewithdrawalphaseasanunconditionedresponse(Drummondetal.,2000).Drummondexplainedthatthesetwoformsofcravingarelikelytocoexist,buttheprobabilityofrelapsewouldbehigherwhenelicitedbycuesbecauseofthegreateraccessibilitytothecravedsubstance.2.1.2.CompensatoryresponsemodelResearchontolerancebySiegel(1983)formedthebasisforthecompensatoryresponsemodel.Hesuggestedthatdrugadminis-trationevokesbothanagonisteffectaswellasacompensatoryresponsetotheagonisteffect,thatis,aresponseoppositetotheinitialdrugeffectsinordertomaintainhomeostasis.Theprocessisalsothoughttoplayamajorroleinthedevelopmentoftolerance.Table1Conditioningmodels.Basicpremise:cravingisanautomatic,unconsciousreactiontoastimulus.ModelSubstanceKeyﬁguresImplicationsforcravingTriggerKeyhypothesesWithdrawalmodelDrugs,alcoholWikler,Ludwig,Stark,O’Brien,Drummond,Cooper,GlautierCravingoccurstoescapeaversivestatessuchaswithdrawaldiscomfortWithdrawalsymptomsorcuesassociatedwithdruguseWithdrawalcanbeconditioned;cravingisapartofthewithdrawalsyndromeCompensatoryresponsemodelDrugs,alcoholSiegelCravingoccurstoescapethediscomfortoftolerance(seenhereasadecreaseinpleasurethatbecomesaversive)TheaversivetoleranceresponseDrugcuesareconditionedandevokearesponseoppositetothedirectionofinitialdrugeffects(tolerance)Opponent-processmodelDrugsSolomon,CorbitCravingoccurstostimulatedrugusesoastoalleviatethediscomfortofcravingandwithdrawalsymptomsWithdrawalsymptomsThecentralnervoussystemofmammalswillspontaneouslyopposediversetypesofaffectivestatesbyproducinganopposingreactionthatwillpersistlongaftertheinitialreactionhasdisappearedIncentivemodel(conditioneddrug-likemodel)Alcohol,drugsStewart,deWit,EikelboomEmphasisisonthestimuli’seffectonbehavior,motivatingthedesiretoexperiencetheagreeableeffectsofthedrug.CravingisastrongmotivationalstateConditioneddrug-relatedstimuliTheaddictivesubstanceprovidespositivereinforcementbecauseofitsactionondopaminerelease.Apleasure-seekingviewofcravingM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623608 Forexample,anagonistdrugeffectofalcoholishypothermiawhichwouldbecompensatedbyhyperthermia(Bakeretal.,1986).Initiallydrugandalcoholconsumptionarethoughttobeappetitiveinordertoexperiencetheeuphoriaofthedrug,butsomeorganismsdevelopatleastapartialtolerancetoappetitivedrugeffectsresultingindiminishedpleasureandevenaversion.TheseacquiredtoleranceresponsesarecompensatoryresponsesthatSiegel(1983)suggestedtobethebasisofthewithdrawalsyndrome.Hehypothesizedthattheaversivetoleranceresponsesconstitutethebasisofurgesinthattheyoverwhelmtheagonisteffectofthedrugorpersistlonger,creatinginthismanneranurgeforreliefofdiscomfort(Bakeretal.,1986).2.1.3.Opponent-processmodelTheopponent-processmodeldevelopedbySolomonandCorbit(1974)assumesthatthecentralnervoussystemofmammalsspontaneouslyopposesdiversetypesofaffectiveorhedonicstates.Initiallyastimulus,whetheragreeableoraversive,leadstoaprimaryaffectivereaction(e.g.,foodleadstodesire;ashockleadstofear).SolomonandCorbitlabeledthisprimaryreactionan‘‘a-process’’.Thea-processwillautomaticallyactivateab-processwhichopposestheinitialreactionbyproducinganoppositereaction.Forexample,fear(ana-process)willactivatetheprocessestoreducefear(b-processes).Thetheorypositsthatb-processespersistlongafterthea-processeshavedisappeared.Inaddition,theyincreasewithrepeatedunconditionedexposure.Relatedtodruguse,SolomonandCorbitarguedthatthea-processescouldreﬂecttheintenserushofpleasurefromopiates.Thesepleasurableeffectsdisappearwithrepeateduseandarereplacedwithaversivewithdrawalsymptoms,reﬂectingtheb-processesandleadingtocraving.Inthismodel,SolomonandCorbitassumedthatthedrugusewasmotivatedtoalleviatecravingandwithdrawalsymptoms.Oncedependent,theappetitiveeffectsofthedrugsupposedlyexertedlittleinﬂuenceastheindividualhadprobablybecomecompletelytoleranttothem.Tosummarizethusfar,thesethreemodelsallagreeonthenatureofurgesasphenomenaproducedbywithdrawalrelatedprocesses.Furthermore,onceaddictionhassetin,theappetitiveoranxiolyticeffectsofopiatesoralcoholareoflittleimportance.Themotiveswitchestouseasamethodtoalleviatewithdrawalsymptoms.Urgesarethusareﬂectionofthewithdrawalprocess.Theopponent-processandcompensatoryresponsemodelsstatethatthewithdrawalresponseshouldbeoppositetothedirecteffectsofthedrugandbecorrelatedtotheleveloftolerance.Thewithdrawalmodelmakesnosuchclaim(Bakeretal.,1986).Whilethesemodelsaccountforcravingduringwithdrawal,theyalsoexplaincravingthatappearsintheabstinentlongafterthewithdrawalsymptomshavesubsided.Supposedlyastateofwithdrawaliscreatedbyacuethathadbeenconditionedlongbeforeduringthepreviouswithdrawalperiods.Animportantshortcoming,however,isthatmanypatientsdonotreportexperiencingwithdrawalsymptomsduringcraving.Thisdiscussionevokesthequestionastotherelationshipbetweencravinganduseorrelapse,asifthetwoformaninseparablepair.Accordingtothesupportersofthewithdrawalmodel,cravingiscausedbywithdrawalandoccurstoseekrelieffromtheassociatedphysicaldiscomfort,whichimpliessubse-quentuseofthesubstance.Itisimportanttoemphasizeherethatwhileweagreethatcravingincreasestheprobabilityofrelapse,weholdthatrelapsemustnotbeassumedtobecausedbycraving.MarlattandGordon(1980)classiﬁedrelapseepisodesinto12categoriesbasedontheperceivedcause.Arelativelysmallproportionofrelapseswasassociatedwithnegativephysicalstates(e.g.,withdrawalstates),positiveaffect,andurges.Bakeretal.(1986)explainedthatMarlatt’sconclusionconﬂictedwiththeoriesthatemphasizedconditionedwithdrawal(O’Brien,1976)orurges(Ludwigetal.,1974)asamotiveforrelapse.MarlattandGordon(1980)suggestedthatanegativeaffectivestatemighthaveinterferedwiththeaddict’scapacitytocopewithapreexistingurge.Anotherexplanationisthattheitem‘‘urge’’onthereasonsforrelapsequestionnairewascheckedonlyifnootherobviousreasonwaslistedasacause.Bakeretal.suggestedthatthisscoringproceduremighthaveunderestimatedtheexistenceofanurgeasacauseforrelapse.2.1.4.IncentivemodelTheincentivemodel(alsoknownastheconditioneddrug-likemodel)(Stewartetal.,1984)positsthatastimulusregularlyassociatedwithalcoholconsumption,suchasabar,becomesconditioned,thusprovokingsimilarphysiologicalandpsychologi-calresponsesasactualdrinking.Ifdrinkingdoesnottakeplace,cravingoccurstopromoteseekingbehaviorinordertoappreciatethepositiveaspectsofalcoholasapositivereinforcementorreward(Anton,1999).Inasimilarmannerwithheroinaddicts,‘‘needlefreaks’’whoinjectinertsubstancescanexperienceeuphoria(O’Brienetal.,1974;Powelletal.,1990).Incontrasttotheotherconditioningmodels,theemphasisofthismodelisonreward.Thedesirestemsfromtheexpectedreward,thoughttoprovokeareleaseofdopamineinthenucleusaccumbens.Powelletal.(1990)foundevidenceforthisintwostudies.Animalsself-administeredopiatesatlevelstoolowtohaveanimpactonwithdrawalsymptoms,thussupportingtheunderlyingmotiveasrewardseekingoverrelief(Beach,1957;WoodsandSchuster,1971).Theincentivemodelassumesthatthememoryofpastpleasureaccountsforthedesire,butitisnotabletoexplainwhysomepeoplewhohaveahistoryofdependenceorabuseofalcoholorotherdrugs,andalsorecallpleasurableexperiencesassociatedwiththesesubstances,donotexperiencecraving.Inaddition,itisprobablethatmemoriesofdisagreeablecircumstancesassociatedwithpastconsumptionexistaswellforbothcraversandnon-cravers.Thismodel’sfocusononlypositivememorieslimitsitsexternalvalidity.Overall,theconditioningmodelscontributedtoourunder-standingofcravingasaphenomenonproducedbywithdrawal-relatedprocessestorelievediscomfortorbyaconditionedstimulusinordertoexperiencepleasure.Thesemodelswerediscredited,however,bynumerousstudiesthatfoundfaultwithsomeoftheirbasicassumptions.Cravingwasmostcommonlyevaluatedthroughexpositiontodrugparaphernaliaoralcohol(sight,smelland/orasmalldose)usingacuereactivityparadigm.Physiologicalmeasures(e.g.,heartrate,bloodpressure,sweat-glandactivity)weretakenaswellastheindividual’ssubjectivereportofcravingandthesetwotypesofmeasureswereexpectedtocovaryandleadtouseintheaddicted(TiffanyandConklin,2000).TiffanyandCarter(1998)reportedthatlittleevidenceexistsforthecovarianceofcue-speciﬁcsubjectiveandautonomicreactions.Furthermore,neithersubjectivenorautonomicmea-sureswereassociatedwithuse.Inareviewof30studiesfromthealcoholcue-reactivityliterature,therewerepossibly73correla-tionsbetweenthesubjectivecravingreportandautonomicmeasures(i.e.,heartrate,bloodpressure,sweat-glandactivity,salivation,andperipheraltemperature).Only14ofthesecorrela-tionswerereported,andoftheseonlythreeweresigniﬁcant.Similarly,afterreviewingeightstudiestoevaluatetheassociationbetweencue-speciﬁcautonomicmeasuresanddruguse,thesesameresearchersidentiﬁed34possiblecorrelations,ofwhich20werereportedandonlythreeweresigniﬁcant.Andﬁnallyintheevaluationoftherelationshipbetweencravingreportanddruguse,usingthesameeightstudies,16correlationswerepossible,12M.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623609 werereported,andonlyfourweresigniﬁcant,threeofwhichcamefromasinglestudybyLudwigetal.(1974)(TiffanyandConklin,2000).Fromtheseanalyses,onecanconcludethatnotonlyistherelittlecorrelationbetweensubjectiveandautonomicmeasures,butcravingdoesnotsystematicallyleadtoconsumption.Thelackofcorrelationleadsbacktoaprinciplequestionregardingwhethercravingisnecessarilyreﬂectedbyphysiologicalmeasures,bysubjectivereport,orbyuse.Furthermore,ifphysiologicalcravingisnotcorrelatedwithasubjectivereportofcraving,howcanwestatethatthephysiologicalreactionsareamanifestationofcraving?Byarguingthatcravingliesoutsideofconsciousawareness(Bakeretal.,2004)?Couldnottheautonomicresponsesimplyreﬂectareactiontoastressor?Thesequestionspointtosomeoftheshortcomingsofthewithdrawalmodels.2.2.CognitivemodelsThecognitivecravingmodelsshareacommontheme:cravingisthoughttoarisefromtheoperationofinformation-processingsystems.Thisviewdistinguishesthesemodelsfromthecondi-tioningmodelsspeciﬁcallybyemphasizingthehigherordercognitivefunctionsasinstrumentalinproducingcravingasopposedtocravingbeingviewedasaprimaldriveorautonomicstate(Tiffany,1999).AccordingtoTiffany(1999),cognitivemodelscanbecharacter-izedbyconstructsbasedonsociallearningtheory(i.e.,expectancy,attributions,self-efﬁcacy,andimitation),informationprocessing,memory,anddecision-making.Themodelsdiscussedwillbetheoutcomeexpectancymodel,thedual-affectmodel,theaffectiveprocessingmodel,andthecognitiveprocessingmodel(seeTable2).2.2.1.OutcomeexpectancymodelWithinthecontextofcognitivesociallearningtheory,Marlatt(1985)proposedamodelbasedontheanticipatoryeffectofpositiveoutcomeexpectancies.Outcomeexpectanciesarebeliefsabouttheconsequencesofalcoholuse:willitproducepleasure,alleviatediscomfort,orboth?Marlattexplainedthatenvironmen-talalcohol-relatedcuescanprovokestrongexpectationsaboutthepositiveeffectsofalcohol,suchaspleasure,relaxation,orrelieffromwithdrawal.Inadditiontotheconditioningandcognitiveaspectsmen-tioned,thereisalsoamotivationalcomponentconsistingoftheintentiontouse,labeled‘‘urge’’.Theynotedthatonemayexperienceacravingandnotanurge–thatis,betemptedbutnotintendtoconsume.Marlatt(1987)explainedthatasequenceofstepsseparates‘‘craving’’fromthe‘‘intentiontoconsume’’composedofmultiplestimulus-responseconnections.AccordingtoTiffany(1995),researchershavenotinvestigatedthedistinctionbetweencravingandurges.Thisisprobablybecausethedeﬁnitionof‘‘urge’’asintentiontoconsumeisspeciﬁctoMarlatt.Manyauthorshavechosentousethetermurgetoreplacethemoreambiguoustermcraving.Littleresearchexiststovalidatetheoutcomeexpectancymodel(Tiffany,1999)andtheattemptstoconﬁrmthetheoryhavenotbeenconclusiveperhapsbecausemorespeciﬁcationsofthefeaturesofthemodelareneeded(Tiffany,1995).AnimportantaspectofexpectancyistherelationshipbetweencravingandBandura’s(1977)conceptofself-efﬁcacy(e.g.,one’sbeliefinone’scapacitytocopewithanurgewithoutusing).AccordingtoMarlattandWitkiewitz(2005),self-efﬁcacywasofutmostimportanceastowhetherexposuretodrugcueswouldresultinrelapse.Inareviewofdrugcravingandsociallearningtheory,Niaura(2000)describedhisstudywith46smokersthatdemonstratedthatefﬁcacyexpectationsmediatedurgeandappearedtobetheﬁnalcommonpathwaytooutcome.Heconcludedbyafﬁrmingthat(1)evidencesupportsaninverserelationshipbetweenefﬁcacyandurges,(2)affectandurgesappeartobeassociated,and(3)efﬁcacyandaffectiveresponsealsoappeartobeassociated.Therelationshipbetweenoutcomeexpectanciesandurges,however,isstillunknown.2.2.2.Dual-affectmodelThedual-affectmodelisbasedupontheassumptionthatanurgeisanemotionthatincreasestheprobabilityofconsuming(Bakeretal.,1986).Twoaffectnetworks,onepositiveandonenegative,arethoughttomodulateurges.Thepositiveaffecturgenetworkiscomprisedofinformationonthedirectappetitiveeffectsofthedrug,suchasexpectanciesofpleasureconsequenttouse.Liketheincentivemodel(Stewartetal.,1984),themodelpositsthataddictivesubstancesdirectlystimulateanappetitivemotivationalTable2Cognitivemodels.Basicpremise:cravingarisesfromtheoperationofinformationprocessingsystems.ModelSubstanceKeyﬁguresImplicationsforcravingTriggerKeyhypothesesOutcomeexpectancymodelAlcoholMarlattAlcoholcuesprovokeexpectationsaboutthepositiveornegativeeffectsofalcoholwhichinﬂuencecraving(desire)andurge(intention)Exposuretoalcohol-relatedcuesthattriggerpositiveexpectationsorrelieffromwithdrawalCravingandurgediffer.Cravingisadesireforpositiveoutcomesfromconsuming,whereasurgeisanintentiontousealcohol.CravingisoneofaseriesofstepsleadingtopossibleconsumptionDual-affectmodelTobaccoBaker,Morse,ShermanAnurgeisanemotionthatincreasestheprobabilityofconsuming.Twonetworksexist(positiveandnegative)thatactivatecravingAmatchbetweeninternalstimuli,externalstimuli(e.g.,cues),andtheprototypicalconﬁgurationofthepositiveornegativeaffectnetworkelicitedatagivenmomentCravingisactivatedbypositiveandnegativeaffectnetworksthataremutuallyinhibitoryAffectiveprocessingmodelofnegativereinforcementTobaccoBaker,Piper,McCarthy,MajeskieandFioreStrongnegativeaffectinterfereswiththeaddict’scapacitiestomanageacravingtouseNegativeaffectTheresponsetointeroceptiveandexteroceptivecuesdependsupontheintensitylevelofnegativeaffect.Strongnegativeaffectproducedbywithdrawalsymptomswillweakenanabstinentaddict’scapacitytocopewiththedesiretoseekorusedrugsCognitiveprocessingmodelAlcohol,drugs,tobaccoTiffanyAcravingisaconstellationofverbal,somatovisceral,andbehavioralresponsessupportedbynon-automaticprocessesrequiringcognitiveeffortObstacletoconsumption(e.g.,desiretoremainabstinentorunavailabilityofsubstance)Cravingisnotthecentralforcebehindconsumptionandisnotnecessaryfordrugseeking.Cravingcanexistwithoutconsuming,andconsumingcanexistwithoutcravingM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623610 system,producingincreasedphysiologicalandbehavioralresponses,suchasincreasedattentiontothedominantresponse.Regardlessofthestrongapproachdirection,thismodeldoesnotsuggestthaturgesinevitablyleadtodrugseekingoruse,butratherincreasetheirprobability.Thepresumedexistenceofapositiveaffecturgenetworkisconsistentwiththeobservationthat‘‘priming’’dosesincreaseratesofself-administrationofthatdrug(DavisandSmith,1976;Stewart,1984;LittandCooney,1999)perhapsbecauseofstimulatingthedesireorcravingtoprolongthepleasure.Studieshaveshownahighrateofreneweddruguseonceanabstinentaddictusesadrug(MarlattandGordon,1980;Brandonetal.,1986).Bakeretal.(1986)suggestedthatthisiscausedbytheactivationofthepositiveaffectnetwork.Paralleltothepositiveaffecturgenetworkisthenegativeaffecturgenetworkthatisthoughttoprovokeanurgebasedonanegativestimulusoraffect(e.g.,depression,fear)asseenintheconditionedwithdrawalmodel(Wikler,1948).Itiscomposedofsuchaspectsaswithdrawalsymptoms,withdrawalcues,knowledgeoftheunavailabilityofthedrugs,negativeaffectthatisdrugornon-drugrelated,andexpectanciesofwithdrawal-likesymptoms.Bakeretal.(1986)suggestedthatpositiveexpectanciesofdesirabledrugeffectsareprobablycodedintothenegativeaffectnetwork:thedrugisallthemoredesirablebecauseofthedeprivation.Activatingthepositiveornegativeaffectnetworkrequiresamatchbetweentheinteroceptivecues,theexteroceptivecues,andtheprototypicalconﬁgurationofthepositiveornegativenetworkelicitedatagivenmoment.Asthecoherenceofthematchbecomesstronger,sowillthemagnitudeoftheurge.Thesepositiveandnegativenetworksareconsideredtobemutuallyinhibitory(Bakeretal.,1986).Theystated,‘‘Owingtothefunctionalpropertiesofournervoussystems–ourmotivationalsystem‘hardware’–weareincapableofprocessingsimultaneouslyintenselypositiveandnegativeemotionalinformation’’(p.307).Whilethemodelclearlysupportsmanyofthekeyconceptsunderlyingthefourwithdrawalmodelspresentedearlier,Bakeretal.(1986)admittedthatitdidnotexplainwhysomedrugusersdonotbecomeaddicted.Inaddition,theystatedthattheyhadprimarilyconsidereddatafromsmokingstudies,reducingthetheory’sexternalvalidity,apointconﬁrmedbyTiffany(1999).Drummond(2001)addedthatthemodelhelpedtounderstandcuereactivityinrelationtotheindividual’sprevailingmoodstate.Onechallengetothemodelisthattheinductionofpositivemoodstatesgenerallydidnotaffecturgewhencueswerenotpresented(Littetal.,1990;TiffanyandDrobes,1991).2.2.3.AffectiveprocessingmodelofnegativereinforcementAsanextensionofthedual-affectmodel,theaffectiveprocessingmodelofnegativereinforcement(Bakeretal.,2004)supportedandreformulatedmanycomponentsofthenegativereinforcementmodelsofdrugaddiction(Solomon,1977;Wikler,1977).Theemphasisinthismodel,however,wasonnegativeaffectproducedbywithdrawalsignals,ratherthanstrictlythephysio-logicalwithdrawalaspects.Unlikethedual-affectmodel,whichintegratedbothpositiveandnegativereinforcementprocesses,Bakeretal.(2004)focusedpredominantlyontheimportanceofnegativereinforcementastheprincipalmotivefordrugusesothataddicteddruguserscould‘‘managetheirmisery’’(p.34).Overall,theaffectiveprocessingmodelmadecontributionstocravingresearchbyemphasizingthevalueofevaluatingnegativeaffectduringcueexposureexperiments.Animportantfactordistinguishingthismodelfromtheotherspresentedhereisthenotionofhotandcoolmemorysystems,introducedbyMetcalfeandMischel(1999)intheiranalysisofdelayofgratiﬁcation.AccordingtoBakeretal.(2004),theresponsetointeroceptiveand/orexteroceptivecuesdependsupontheintensitylevelofnegativeaffect.Atalowlevelofnegativeaffect,suchaswhenanaddictexperiencingnegativeaffecthasaccesstoavailabledrugs,drugusetendstooccuratanunconsciouslevel.Theaddictpreconsciouslydetectsslightinteroceptivesignalsofnegativeaffect(e.g.,earlywithdrawalsymptoms)thatcreateanurgethatleadstodrugseekingoruse.Onthecontrary,ifnegativeaffectishigh,suchaswhenadditionalstressorsarepresent(e.g.,interpersonalconﬂict),thefocusoftheaddictishighlyinﬂuencedbyhotinformationprocessing.Thiscreatesabiasofattentiontowardnegativeaffectandperceivedthreatsthatinturnleadtoabiasofresponse:non-drugincentivevaluesdecreaseasdrugincentivesincrease.Thestrongnegativeaffectweakenstheamountandeffectofcoolinformationprocessingthatmightotherwiseenabletheaddicttoregulateaffectandcopewiththedesiretoseekorusedrugs.Inthecaseofmoderatenegativeaffect,cognitivecapacitieswouldmostlikelybeimplementedresultinginadecreasedlikelihoodofuse.Theprinciplecriticismsoftheaffectiveprocessingmodel,likethenegativereinforcementconditioningmodelsarethat(1)someaddictsrelapselongafterwithdrawalsymptomsshouldhaveceased(RobinsonandBerridge,2003),implyingthattheseverityofwithdrawalisnotwellcorrelatedwithdruguse,and(2)thereliefofaversivewithdrawalsymptomscannotbeanimportantdeterminantofaddictionbecausesomedrugs(e.g.,tobacco,cocaine,andbuprenorphine)arehighlyaddictivewithoutproduc-inghighlyunpleasantsyndromes(Jaffe,1992;Lyvers,1998).Inresponsetotheﬁrstcriticism,Bakeretal.(2004)donotmakeaconvincingargumenttoaccountforrelapsewithoutphysiologicalwithdrawalsymptomsinhumansoranimals.Regardingthecorrelationbetweenwithdrawalseverityandrelapse,however,theypointedoutastudyinwhichrelapseoccurredatthepeakofwithdrawalinsmokers(Kenfordetal.,1994).Theyfurthernotedthenecessityofassessingthefulldimensionoftobaccowithdrawalandnegativestates,asopposedtoonlyself-report,becausetheyhadfoundthateachdimensionprovidedavaluableindexofrelapsevulnerability(Piaseckietal.,2003a,b).Indexingofaffectiveprocessing,theyasserted,isnotcompletebyself-reportalone.Thereisahighlyphysiologicalcomponenttoevaluateaswell.Regardingthesecondcriticism,Bakeretal.citedstudiesthatdemonstratedthatnicotine,cocaine,andbuprenorphineproducewithdrawalsyndromesthatarepredominantlycomposedofnegativeaffect(Fudalaetal.,1990;LagoandKosten,1994;Jorenbyetal.,1996;Coffeyetal.,2000).2.2.4.CognitiveprocessingmodelThecognitiveprocessingmodel(Tiffany,1999)positsthatcravingoccurswhenhabitualdrinkersaccustomedtonolimitsontheirconsumptionarepreventedfromdrinkingeithervoluntarilyorinvoluntarily.Forexample,ifafterseeinghisorherfavoritedrinkanindividualdecidestoorderandconsumeit,heorshewillnotexperiencecravingbutratherrespondinanautomaticmannerwithoutcognitiveeffort.Ontheotherhand,ifanobstaclepreventsconsumption,heorshewillexperienceacraving,consideredbyTiffanytobeanon-automatic,effortfulresponse.Commitmenttoabstinenceisaself-imposedobstaclethatprobablyactivatescravinginthesamewaythatamaterialobstaclewould,suchasinaccessibilityofalcoholtoanactivedrinker.Ofcentralimpor-tancetothemanifestationofcravingistheobstacle.Howtheobstacleisperceivedandinterpreted(e.g.,minor,problematic,temporary,orlong-term)willaffectthestrengthoftheassociationbetweencuesandthelevelofdesiretheycreateaswellastheoutcomeofcravingmanifestedasrelapse(Tiffany,1990).Someauthorshavefoundthatcravingdisruptscognitivefunction.Forexample,peopleintreatmentforalcoholismwhowereexposedtoalcoholcueshadaslowerreactiontimeonacognitivelydemandingtaskthanwhenexposedtoneutralcuesM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623611 (Sayetteetal.,1994).Sayetteetal.havecontributedmuchtoourunderstandingofcravingandtheperceptionoftimewithsmokers.Theyfoundthathigh-craverspredictedaperiodoftimetobelongerthanlow-craversinastudyontemporalcognition.Theyalsofoundthatsmokersinahighcravingstateoverestimatedurgeintensity,anticipatingthatitwouldgrowinmagnitudeoveraperiodof45minofsmokingabstinence.Whenasecondgroupofdeprivedsmokersinacravingstatewassubmittedtothesametypeofsmokingcues,thelevelofurgeintensitydidnotriseovertime(Montietal.,2004).Howdothesecognitiveﬁndingsregardingcravingrelatetorelapseoruse?Researchontimeperceptionhasshownthatduringperiodsofself-restraint,peoplearelikelytopaymoreattentiontotimeandthusperceivean‘‘extendednow’’state.Thisseemstoreducetheircapacityforself-regulationforsubsequenttasks(VohsandSchmeichel,2003).Translatedtocravingsituations,anindividualwhoisexperiencingcravingbecauseheorshewishestoremainabstinentandisinaself-restraintstatewouldperceivetimeaspassingslowly.Heorshemustthusresistdruguseforwhatseemslikealongerperiodthanonewhoisnotcraving,thusincreasingthedifﬁculty.Inasimilarmanner,theriskofsuccumbingtotemptationishigherforpeoplewhoareinacravingstateandﬁrmlybelievethatthisstatewillintensifyorremainunlesstheyconsume.Rohsenowetal.(2001)showed,however,thatalcoholicsintreatmentwhothoughttheirurgewouldnevergodownexperiencedadownwardturnintheirurgeafterabout15minduringcueexposureinwhichdrinkingwasnotallowed.Sayette(2004)offeredfurtherexplana-tionsfordruguseprovokedbycravinginhisstudieswithsmokers.Whendeprivedofnicotine,thesmokersfocusedmoreonsmokingrelatedstimuli,andthefocusonthestimuliwaspositivelycorrelatedwiththecraving.Thesesmokersinfactalteredtheirfocustopositiveratherthannegativeconsequencesofsmoking.Anotherassumptionofthecognitiveprocessingmodelisthattheprocessesthatcontrolcravingandthosethatcontrolconsumptionaretwoindependentsystems.Inotherwords,onecanseekandconsumealcoholwithoutcravingandonecancravewithoutconsuming.Asdescribedearlier,numerousstudieshavesupportedthiscoreassumption(Tiffany,1990;TiffanyandCarter,1998;TiffanyandConklin,2000).Furthermore,instudiesusingcueexposurethatevaluatedtheprincipalcauseforrelapse,cravingwasrarelymentionedasadirectcause(TiffanyandCarter,1998).Withitsemphasisontheautomaticbehaviorofaddiction,thecognitiveprocessingmodelprovidedanexplanationforwhyabstinentaddictedindividualscanrelapselongafterwithdrawalsymptomshaveceased.Amentalschemaoractionplanofpastuseisactivatedbyaspeciﬁcconﬁgurationofexternalandinternalcuesandconsumptionoccursautomaticallywithoutintention,craving,oreffort(Tiffany,1990).Thecognitiveprocessingmodelconcurswiththeaffectiveprocessingmodelintwokeyareas.Bothsuggestthatagreatdealofcognitiveeffortisnecessarytomanageacravingordrugurgeforindividualswithanobjectiveofabstinence,withBakeretal.attributingthedifﬁcultytotheinterferenceofaffectandTiffanytothecognitiveeffortnecessarytodealwithcraving.Secondly,bothmodelsagreeonthenotionofautomatizeduseinactivedruguserswithaccesstodrugs(e.g.,withouteffortforTiffanyandatapreconsciouslevelforBakeretal.,2004).2.3.PsychobiologicalmodelsTheunifyingthemeofthesemodelsisthatcravingisdirectlyinﬂuencedbybiologicalneuralsystems,suchasneuralcircuitry,rewardsystems,andneuroanatomy.Emphasisisplacedonindividualdifferencesandonmotivationfordrinkingbehavior.Inaddition,eachmodelcanaccountforobsessivecraving.Themodelspresentedwillbethethree-pathwaypsychobiologicalmodel,theincentivesensitizationmodel(knownalsoastheneuroadaptivemodel),theneuralopponentmotivationalmodel,thetemporal-differencereinforcementlearningmodel,theuniﬁedframeworkforaddictionsmodel,theneuroanatomicalmodel,andthemodelofinteroceptivedysregulation(seeTable3).2.3.1.Three-pathwaypsychobiologicalmodelThethree-pathwaypsychobiologicalmodelofcraving(Verheuletal.,1999)isbaseduponthepremisethatalcoholcravingreferstoastrongdesiretoconsumewithoutincludingnotionssuchasexpectancies,precipitantfactors,orconsequencesinthedeﬁnition.Thisstreamlineddeﬁnitionpermittedthetermtobeusefulasapredictorofalcoholabuseorrelapse.Verheuletal.arguedthatifcravingwereviewedasanticipatory,theconceptwouldbelimitedbytheindividual’scognitivecapacitiestoanticipatetheeffectsofaproductortheactivityofconsuming.Theyalsopointedoutthatanticipatorymotivationmodelsofcraving(e.g.,Marlatt’soutcomeexpectancymodel)didnotaccountfortheobsessivetypeofcravingthatischaracterizedbyrecurrentandpersistentthoughtsaboutalcohol.Verheuletal.concludedthattheconfusingnatureofcravingistheoutcomeoftryingtodeﬁneittoobroadly.Inaddition,theyfoundtheexistingscalesforassessmentinadequate,recommend-inginsteadthatcravingbeevaluatedbyassessingtheunderlyingpsychological,psychophysiological,and/orneurochemicalchar-acteristicsoftheindividual.Morespeciﬁcally,thethree-pathwaymodelfocusesonpersonalitystyles,abilitytobeconditioned,sensitivitytoalcohol’seffects,andneuralcircuitry(i.e.,neurotransmittersystems)toexplaincraving.Threeetiologicalpathwaysarethoughttoexistbasedonthemotivatingfactorsunderlyingthedesiretodrink.Theﬁrstofthese,rewardcraving,involvesthosepeoplewhoconsumebecauseofadesireforthepositiveeffectsofalcohol.Thepersonalitystyleassociatedwiththeseindividualsistypicallythatofrewardseekers,thatis,theyhaveahighsensitivitytopositivereinforcementorrewardingevents.Theyarenotgenerallyextroverts,noveltyseekers,orsensationseekers,butratherseektheneurotransmitterchemicalrewardinvolvingtheopioidergic/dopaminergicsystem.Verheuletal.(1999)suggestedthatthiscategorymightcontinuallyseekrewardstocompensateforalowlevelofcorticalarousal.Thesecondpathwayinvolvesthosepeoplewhoconsumetorelievetensionorarousal,labeledreliefcraving.Verheuletal.describedthepersonalitystyleassociatedwiththistypeasstressreactive,deﬁnedaspossessing‘‘theanxioussensitivitytobothexternalstressfuleventsandinternalphysiologicalarousal’’(p.212).Theauthorssuggestedthelikelyassociationofthistypeofcravingwiththepsychophysiologicalsystemknownaseithertheaversivemotivationalsystemorthebehaviorinhibitionsystem(BIS)(Fowles,1980,1988;Gray,1987).Thissysteminhibitsappetitivemotivatedbehaviorwhenconditionedstimuliorcuesarepresentbysignalingthataversiveconsequenceswillfollowiftheindividualactsontheappetitivecues(Verheuletal.,1999).ReliefcravingispossiblyduetoadysregulationintheGABAergic/glutamatergicsystems.Theseindividualsarehypothesized,inneurobiologicalterms,tomanifestneuralhyper-excitabilityduetoincreasedexcitatoryorglutamatergicneurotransmission,de-creasedinhibitoryorGABAergicneurotransmission,orboth.Finally,thethirdpathway,obsessivecraving,involvesthosewhoareincapableofcontrollingtheirintrusivethoughtsaboutdrinking,includingtheamountoftimespentinanefforttoresistalcohol-relatedthoughts.Thepersonalitystyleassociatedwiththispathwayischaracterizedbylowrestraintordisinhibition,thatis,‘‘theinabilitytorestrainimpulsesinthefaceofimpendingappetitiveandaversivestimuli’’(Verheuletal.,1999)(p.213).M.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623612 Table3Psychobiologicalmodels.Basicpremise:cravingcanbeexplainedatleastinpartbybiologicalfactorswithanemphasisonmotivationalcomponents.ModelSubstanceKeyﬁguresImplicationforcravingTriggerKeyhypothesesThree-pathwaypsychobiologicalmodelAlcohol,drugsVerheul,VanDenBrink,GeerlingsPersonality,typeofmotivationtoconsume,andindividualdifferencesinneurotransmittersystemsformthreedistinctpatternsofcraving:reward,relief,andobsessivecravingDesireforpositiveeffects,desireforrelief,thoughts,andobsessionsIndividualdifferencesinpsychological,psychophysiological,and/orneurochemicalcharacteristicsformthreedistinctpatternsofcraving.CravingisassumedtopredictrelapseoruseIncentive-sensitizationtheory(neuroadaptivemodel)Drugs,alcoholRobinson,BerridgeThelong-termuseofsubstancesprogressivelycausesneurobiologicalchangesthatmaybepermanent.Whenconsumptionstops,cravingoccurstoreacquirehomeostasisinanimbalancedbrainBrainimbalanceinearlyabstinence;inlaterwithdrawal,theactionofstressonrewardmemoriesthatinturnactonbrainsystemsresponsibleforcravingNeuralsystemsinvolvedin‘‘wanting’’(i.e.,cravingconsideredtobecompulsiveinnature)operateindependentlyofthoseinvolvedin‘‘liking’’(i.e.,pleasantaffectiveresponse)TheoryofneuralopponentmotivationAddictivesubstancesKoob,LeMoalCravingarisesfromtheactionofmemoryoftherewardingeffectsofdrugusesuperimposedonanegativeemotionalstateCues,negativeemotionalstate,memoriesofrewardingeffectsExcessivedruguseactivatestheantirewardsysteminordertoproducenegativehedonicvalencesoastolimitthereward.Long-termuseofdrugsdysregulatestheneurochemicalfunctionsresultinginanallostaticstate,deﬁnedasachronicdeviationoftheregulatorysystemfromitsnormal(homeostatic)operatinglevel.BothneurotransmitterchangesandtheactivationoftheantirewardsystemcreateapowerfulstateofnegativereinforcementsupportingcontinueduseTemporal-differencereinforcementlearningmodelCocaineRedishAsurgeofdopaminefollowingdrugusecausesanexcessivevaluessignalforafuturedrugreward.Avaluessignalisaconceptresemblingcravingdeﬁnedastheexpectedfuturerewarddiscountedbytheexpectedtimetothereward.ThesensitivitytothecostofthisrewardisreducedDrugusebecauseitcausesaneurophysiologicaleffectviadopamineThelearningofthevalueofarewardisalteredbydruguse,pushingapersontowardsirrationalbehaviorinoverselectingactionsleadingtodruguseoverlargernon-drugrewardsUniﬁedframeworkforaddictionAddictivesubstancesRedish,Jensen,JohnsonCravingarisesfromanovervaluationofexpecteddrugoutcomes,anovervaluationoftheexpectedvalue(pleasure)ofapredictedoutcome,andasaconsequenceofthechangesinallostasisOvervaluationsoftheexpecteddrugoutcome,overvaluationoftheexpectedpleasureofconsumingthedrug,anddysregulatedsetpointcausedbyallostasisAddictionisabroad-spectrumdisorderthatconsistsof‘‘failuremodes’’orerrorsinthedecision-makingprocess.Thesefailuremodescanbegroupedinto10vulnerabilities,someofwhichleadtocravingNeuroanatomicalmodelAlcoholAntonThedegreeofcravingresultsfromtheinteractionbetweenmemoriesandbrainstructuresMemories,cues,alcoholingestion,and/orstrongemotionsBrainstructuresmediateanindividual’ssubjectiveresponsetocuesandarehighlyindividualized(e.g.,nucleusaccumbens,amygdala,dorsallateralprefrontalcortex,orbitofrontalcortex,andbasalganglia)ModelofinteroceptivedysregulationDrugsPaulus,Tapert,SchulteisCravingarisesfrominteroceptivebodysensationsandmotivationstouseasubstance.Thehedonicvalueofthestimuli(i.e.,thedegreeofcraving)istermedalliesthesiawhichisregulatedbyinteroceptiveprocessingDysregulationoftheinternalstateTheinsularcortexfunctionisdysregulatedindrugaddicts.Thisresultsinanon-adaptiveadjustmentofthebodypredictionerror(thedifferencebetweenthevalueoftheanticipatedsensationandthevalueofthecurrentinteroceptivestate)M.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623613 Obsessivecravingmayresultfromaserotonindeﬁciency(Ciccocioppo,1999).Itisgenerallyassumedthatserotonin(5-HT)deﬁciencyisinvolvedinmooddysregulation.Theserotonergicneurotransmittersystemis,associated,however,withmanypsychiatricillnesses,and5-HTdisturbanceisthusconsiderednosologicallynon-speciﬁc.VanPraagetal.(1987)pointedoutthatserotonergicdysfunctioncorrelatedwithspeciﬁcpsychopatholog-icaldimensionssuchaslackofcontroloverimpulses,mood,andattentional/cognitiveprocesses.Verheuletal.(1999)suggestedthatthepresenceofthesepsychopathologicaldimensionspredis-posedtoobsessivecravingandpossiblerelapse.Thethree-pathwaypsychobiologicalmodelisbasedonadeﬁnitionofcravingassimplyastrongdesiretodrinkalcohol,implyingtheintentiontoconsume.Cravingshouldthusbeabletopredictrelapseoruse.Ingeneral,theauthorsfavoraconservativeapproachtotheetiologicalpathwayofcraving,whilecautioningagainstlimitingtheetiologytojustconditioningoranticipatory/expectantqualities.Theetiologicalbasisisthusfreetovaryaccordingtoindividualdifferences.Thetheoryisoriginalandheuristic,takingintoconsiderationthepersonalityandemotions,whileincludingtheneurochemicalfactorsinvolvedincraving.Ineachofthethreepathways,itunitespersonalitytraitswithaspeciﬁctypeofcravingmotivationandneurotransmittersystem.Aweaknessisthatitseemstooeconomical,usingtoofewconceptstoaccountforcraving.BecauseVerheuletal.equatecravingwithintentiontoconsume,theydonotattempttoexplainhowcravingoccurswithoutconsumption(afrequentoccurrenceintreatmentunits)orforthatmatterhowconsumptionoccurswithoutcraving.2.3.2.IncentivesensitizationmodelTheincentivesensitizationmodel,alsoknownastheneuroa-daptivemodel,positsthatcravingislinkedtoneuralcircuitry,neuralsubstrates,andrewardsystemsinthebrain(RobinsonandBerridge,1993).Theunderlyingmechanismofcravingisthoughttobearesultofahyper-sensitizationofthedopamineneuraltransmittersystemthatinturnincreasestheincentivesalienceofdrugs.‘‘Incentivesalience’’referstoapsychologicalprocessthatenhancesthesalienceofthestimuli,makingthemmoreattractive,‘‘wanted’’incentivestimuli.Thisincreaseinincentivesalienceturnsordinarywantingintoexcessivedrugcraving(RobinsonandBerridge,1993).Theseauthorsreportedthatthelong-termuseofalcoholandotherdrugsprogressivelycausesneurobiologicalmodiﬁcationsthatmaybepermanent(RobinsonandBerridge,1993).Thesemodiﬁcationsoradaptationstakeplaceasthebrainattemptstomaintainhomeostasiswhileinthepresenceoftheaddictivesubstance.Anactiveuser,especiallyearlyinthedependencestages,isfrequentlyunawareofthesechangesandtypicallydeniesexperiencesofcraving.Ifdrugoralcoholconsumptionceases,thesemodiﬁcationsarethoughttoprovokeanimbalanceincerebralactivitythatresultsincraving.Cravingmanifestsitselfdifferentlyaccordingtowhetheroneisinearlywithdrawalorlaterrecovery.Earlywithdrawalischaracterizedbyastateofgeneralinstabilityasthebrainissuddenlyinanalteredstate.Thiscanleadtofeelingsofanxiety,sleepdifﬁculties,cardiovascularhyperactivity,andperhapsareductionintherewardstatesresultingindepressionandlackofmotivation.Accompanyingthediscomfortisadesireorcravingforthesubstancetoalleviatetheimbalance.Inlaterrecovery,thealteredbrainfunctionsreturntotheiroriginalstateandcravingradicallydecreases.Yetduringthisperiod,individualswillexperienceurgesorcravingsthatseemtoappearsuddenly.Thisreactivationofcravingcanbetriggeredbystresswhichmayactivatetherewardmemory.Rewardmemoriesarecharacterizedbyheightenedattentiontoenvironmentaloremotionalcueselicitingmemoriesoftheagreeableeffectsoftheaddictivesubstancesormomentswhentheuseofdrugsservedtodecreasenegativefeelings.Therewardmemoriesmayalsoreactivateneurochemicalprocessesassociatedwithpastexperiencesofdrugusethatinturnactivatethebrainsystemsresponsibleforcraving,asillustratedbytheclassicalconditioningmodel(Anton,1999).Athemecentraltotheincentivesensitizationtheory,publishedin1993andfurtherclariﬁedoverthenext15years,wasthatofdistinguishing‘‘wanting’’from‘‘liking’’.Althoughthetwocanoccursimultaneously,theycanalsodiverge.Forexample,addictivebehavior(wanting)canoccurwithouttheexpectationofpleasure(liking).Wantingalsocanoccurinspiteofseriousdisincentivessuchalossoffamily,job,andreputation.RobinsonandBerridge(1993)explainedthisasfollows:‘‘Sensitizationoftheneuralsystemsresponsibleforincentivesalience(for‘wanting’)canoccurindependentlyofchangesinneuralsystemsthatmediatethesubjective,pleasurableeffectsofdrugs(drug‘liking’)’’(p.247).Both‘‘wanting’’and‘‘liking’’areexpressedexplicitlyandimplicitly.‘‘Wanting’’ismotivationallygroundedandﬂuctuatesaccordingtothelevelof‘‘incentivesalience’’orrewardvalueoftheaddictivesubstance.Explicitly‘‘wanting’’isdemonstratedthroughconsciouscravingandgoal-directedplans.Implicitlyitcanbeevokedduringexposuretoaconditionedstimulusoracueandappearsasanunconsciouscraving(RobinsonandBerridge,2008).‘‘Liking’’,ontheotherhand,ishedonicincharacterandisconsideredtobeanemotionbyRobinsonandBerridgeasitcharacterizeshowapersonfeelsabouttheexplicitpleasureofasubstance.Thehedonicreactioncanalsooccur‘‘implicitly’’withoutanyapparentawarenessofthestimulus(BerridgeandRobinson,2003).Thiswasillustratedinastudyinwhichabehavioralreaction(consumingmoreofafruitdrink)indicatingahedonicresponsefollowedasubliminalstimulus(briefviewofhappyfacialexpressions).Thesubjectssubsequentlyratedthedrinkashigherinpleasantness,monetaryvalue,andattractivenessdemonstratinganemotionalreactionoutsideofawareness(BerridgeandWinkielman,2003).Intwostudies,RobinsonandBerridgefoundthatbymanipu-latingthemesolimbicdopaminesystem,changesresultedin‘‘wanting’’butnotin‘‘liking’’,thusprovidingbiologicalevidenceforthedistinctionbetweenthetwo(BerridgeandRobinson,1998;RobinsonandBerridge,2003).Severalotherstudiessupportedthenotionthatdopaminedoesnotmediatethesubjectivepleasureofdrugrewards(Braueretal.,1997;Leytonetal.,2002;Volkowetal.,2002;Wachteletal.,2002).Incentivesaliencemanifestedaswantingisthusconsidereddistinctfrompleasureorlikingprocesses(RobinsonandBerridge,2008).Inaddition,learningplaysamajorroleintheincentivesensitizationmodelasitinteractswiththemotivational(wanting)andtheemotional(liking)dimensionsandthusdirectsmotivationtospeciﬁcandappropriatetargets.Learningiscomposedoftwotypes:rewardexpectancyandconditioning,bothclassicalandoperant(BerridgeandRobinson,2003).Theconditioningorassociativelearningprocessescanmodulatebehavioralexpressionofneuralsensitizationatspeciﬁcplacesandtimesbutcanjustaswellinhibititsexpressionatothers.Thismechanismexplainswhyaddictswantdrugsmostindrug-associatedcontexts.RobinsonandBerridge(2008)challengedtheassumption,however,thatstronglyautomatizedstimulusresponsehabits,becausetheyarewelllearned,necessarilyleadtocompulsivebehavior.Theypointedoutthat‘‘addictsintherealworldarenotstimulusresponseautomatons;theyare,ifnothingelse,quiteresourceful’’(p.3138).Incentivesensitizationtheorymergedtheemotional,motiva-tional,andlearningaspectsofcravingintoamodelwithastrongbiologicalcomponent.Itisacomprehensivetheorycoveringbothearlywithdrawalandlong-termmaintenancephasesexplainingwhyaddictscontinuetowantdrugsevenafterlongperiodsofM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623614 abstinenceandevenintheabsenceofanegativeaffectivestate(RobinsonandBerridge,2008).Italsoexplainedhowcravingdoesnotleadsystematicallytoconsumptionandhasbeentestedandsupportedbysolidempiricalevidence.2.3.3.TheoryofneuralopponentmotivationKoobandLeMoalproposedaneurobiologicalframeworkintheirtheoryofneuralopponentmotivationforunderstandingaddictionthatconcurswithsomeofthebasicpremisesoftheincentivesensitizationmodel(RobinsonandBerridge,1993)andextendstheopponentprocesstheory(Solomon,1977).Itthusintegratedthephysiologicalconceptsofsensitizationandcoun-teradaptation(KoobandLeMoal,1997,2001,2005,2008).Inaddition,theyattributedtheaddictionprocesstothepredomi-nanceofwithdrawalnegativeaffectasseenintheconditioningwithdrawalmodelsandfurtherdevelopedbyBakeretal.(2004).Indeed,theystatedthatduringabstinence,thereisadevelopmentofaneworaresidualnegativeemotionalstate(KoobandLeMoal,2008)aswellasanxietyordysphoria.Duringprolongedabstinence,cravingorwantingmaybecausedbyanoveractivemesocorticolimbicdopaminesystembecauseofpriorsensitizationbydruguse.KoobandLeMoal(2001)postulatedthatchronicdrugexposuresetsinmotionallostasis,deﬁnedas‘‘astateofchronicdeviationoftheregulatorysystemsfromtheirnormalstateofoperationwithestablishmentofanewsetpoint’’(p.102).Duringallostasis,anorganismattemptstomaintainstabilitybyexertingconsiderableenergyinordertoresetthedrugrewardsetpoint.Anallostaticstatediffersfromhomeostasisinthatitinvolvesafeed-forwardmechanismratherthanthenegativefeedbackmechanismofhomeostasis.Inallostasis,thereisacontinuousmatchingofneedtoresources,requiringcontinuousreadjustmentofallparameterstonewsetpoints(KoobandLeMoal,2008).Theseadjustmentsderegulatethebrain’srewardsystem.Becausethesetpointisnowoutsidethenormalhomeostaticrange,asmallchallengecouldprovokealossofcontroloverdrugintake(KoobandLeMoal,1997,2001).Anyenvironmentalfactorthatchallengeshomeostasisishypothesizedtobemetwithcounteractionsaswehaveseeninopponentprocesstheory(Solomon,1977).Asdescribedearlier,opponentprocesstheorypositsthattheprimaryhedonicresponsetoastimulus,thea-process,producesanopposingb-processthatoccursafterthehedonicresponseandpersistslongafter,reﬂectedbytheaversivewithdrawalsymptomsandcraving.KoobandLeMoal(1997,2001)extendedthistheorybyproposingthattheb-processactuallyappearsshortlyafterthebeginningoftheaprocessandmaybeinstrumentalinchangingthehedonicsetpointbyspeciﬁcallypreventingthedrugrewardsystemfromreturningwithinthenormalhomeostaticrange.Theyevokedthepossibilitythattheb-processmaygetprogressivelylargerduringintermittentdrugtakingandthatprocessesofsensitizationandcounteradap-tationareindependentlyactiveatdifferentpartoftheaddictioncycle(KoobandLeMoal,1997,2001).TherecentworkofKoobandLeMoal(2008)hasfocusedontheneuroadaptivechangesinthebrainemotionalsystemsduringaddiction.Theirworkisbasedonthepremisethatanaddictionmovesfromaninitialimpulsivedisorderbasedonpositivereinforcementtoacompulsivedisorderdrivenbynegativereinforcement.Theexcessiveutilizationofthedrugcreatesanoveractivationofthebrainrewardsystemwhichiscomposedofcircuitsinvolvedinpositivereinforcement.Thisexcessiveactivitytriggersthebrainstresscircuitorantirewardsystem,producingnegativehedonicvalenceinordertolimitthereward.Initially,drugtakingsuppressestheantirewardsystem,butinlongterm,dysregulationoftheunderlyingneurochemicalfunctionsoccursresultinginanallostaticstate.Speciﬁcally,dopamineandopioidpeptidefunctiondecreaseandcorticotrophin-releasingfactor,norepinephrine,anddynorphinactivity,amongothers,increaseproducingaversionandotherstress-likestates(Aston-Jonesetal.,1999;Koob,2003).Theseneurotransmitterchangesalongwiththeactivationoftheantirewardsystemcreatepowerfulnegativereinforcement(KoobandLeMoal,2008).Cravingarisesfromtheactionofmemoryoftherewardingeffectsofdrugusesuperimposedonanegativeemotionalstate(Koob,2000).KoobandLeMoaldelineatedtwotypesofcraving.Theﬁrst,Type1,wasinducedbydrugsorthememoryofcuesthathadpreviouslybeenpairedwithdruguse.Type2cravingwasmorepowerfulinthatitconsistedofaType1cravingsituationsuperimposedontoachangeinemotionalstatecharacterizedbydysphoria,anxiety,oraresidualnegativeemotion.Unlikethecognitiveprocessingmodel,cravingthatdoesnotresultinresumeddruguseisnotexplainedbythismodel.2.3.4.Temporal-differencereinforcementlearningmodelAlearningmodeldrawingontheconceptofincentivesaliencefromtheincentivesensitizationmodelthatattemptstoexplainthespeciﬁcityofdrugrewardscomparedtonaturalrewardswasproposedbyRedish(2004).Inthetemporal-differencereinforce-mentlearningmodel(TDRL),actionsareselectedtomaximizefuturerewards.Thesedecisionsarebasedonthestrengthofavaluesignal,deﬁnedastheexpectedfuturerewarddiscountedbytheexpectedtimetothereward.Thisvaluesignalisthoughttobecarriedbydopamineandproducetemporal-differencelearninginthenormalbrain.Itishypothesizedtoguidedecisionsandresembles‘‘wanting’’morethan‘‘liking’’asdescribedintheRobinsonandBerridgemodel(BerridgeandRobinson,2003;Redish,2004).TDRLisbasedonassumptionsaboutcocaine,hypothesizedtoproduceaphasicincreaseindopaminedirectly.Thisneurophysi-ologicaleffectondopaminesignalspushesapersontowardsirrationalbehavior,leadingtheauthortostatethataddictionisinherentlyirrational.Inanatural(non-drug)rewardsituation,forexample,Redishexplainedthatpeoplewillworkharderformorevaluablerewards;eachchoicecomeswithacost,aphenomenonknownaselasticityineconomics.Thesamemechanismsarethoughttobeusedfornaturalrewardsasdrugrewards.Theuseofaddictivedrugsdoesshowsensitivitytocost.Comparedtonaturalrewards,however,thesensitivitytodrugrewardsisless‘‘elastic’’,leadingtoirrationalchoicesofdrugrewardsregardlessofcost.Themodelexplainshowanaddictoverselectsactionsthatleadtoprobableuse(Redish,2004),butitisyettobeempiricallyproven.2.3.5.UniﬁedframeworkforaddictionmodelAnextensiveandcomplexcomputationaladdictionframeworkwasrecentlyproposedbyRedishetal.(2008)knownastheuniﬁedframeworkforaddiction.Addictionaccordingtothistheoryiscomposedof10vulnerabilitiesindecision-making,referringtoerrorsinthedecision-makingprocessthatmayoverlaporremainindependent.Eachvulnerabilitywouldneedaspeciﬁctreatmentregimen.Thetheoryisbasedupontheunderlyingassumptionoftheexistenceoftwosystems,aplanningsystem(basedonfuturepossibilitiesandtheirconsequences)andahabitsystem.Theplanningsystemisﬂexiblewhilethehabitsystemisrigid.Addictedpeoplegenerallybegindrugusewiththeplanningsystem,butwithhabitualuse,continueinthehabitsystem.Theauthorspointoutthatwhatisuniquetothistheoryisthenotionthatmisperformancemayoccurineachofthesystemsaswellasintheirinteraction.Inaddition,theerrorsor‘‘failuremodes’’arepredictedtobespeciﬁcandpartialaccountingforvulnerabilityinspeciﬁccontextsbutnormaldecision-makinginothercontexts(Redishetal.,2008).AsopposedtoLeMoal(2008),Redishetal.donotagreethatalladdictspassthroughasinglesequenceintheaddictiveprocess(i.e.,fromimpulsivetocompulsiveuse),butM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623615 ratherthataddictivebehaviorlikeotherbehaviorsmaybecontrolledbybothsystemsoroneortheotherdependinguponthestageoflearningandspeciﬁctaskrequirements.Theauthorsgroupedmanyexistingaddictiontheoriesunderthecategoryofdecision-makingprocessesthatcoverabroadspectrumofetiologies.Craving’setiology,however,isnotyetclearinthecontextofdecision-making,althoughtheauthorsproposedthatcravingisprovokedbyanovervaluationofexpecteddrugoutcomes(vulnerability4)fromtheplanningsystemwhichiscalculatedfromthelevelofneedandthevalueoftheoutcomesatisfyingthatperceivedneed(Redishetal.,2008).ThisisthemostimportantvulnerabilityaccordingtoBerridgeetal.(2008)andwouldcorrespondtotheir‘‘wanting’’orcravingterm.AccordingtoRedishetal.(2008),cravingisalsoprovokedbyanovervaluationoftheexpectedvalue(pleasure)ofapredictedoutcome(vulnerability3).Itcanalsobeaconsequenceofthechangesinallostasis(vulnerability2)whichinturnchangetheevaluationofexpectedoutcomesofdrugaddiction.Severalweaknessesofthetheoryhavebeenreportedbytheauthorsandtheirpeercommentators.Notably,theproposedframeworkisaﬁrstattemptandwillneedvalidating,extending,andcorrecting.Inaddition,thelistofvulnerabilitiesremainsincomplete.Severalpeercommentatorshavepointedoutamajoromissionwhichistheabsenceofaffectiveprocessesasavulnerability(KiviniemiandBevins,2008;LeMoal,2008).Thetwo-systemtheoryhasbeencritiquedasincompleteaswellbecauseitdidnotincorporateadistinctPavloviancomponentforexplainingselectionmechanisms(KiviniemiandBevins,2008;OstlundandBalleine,2008).Inresponsetothepeercommentaries,Redishetal.(2008)proposedarevisedthreepartsystemintheirframeworkinordertoincludethePavloviancomponent.Theovervaluationofthehabitsystem(vulnerability7),manifestedasamindlessorroboticformofdruguse,dependsuponthevalidationofthepreviouslypresentedTDRLexplanationofdopaminesignaling(Redishetal.,2008)whichhasnotbeenempiricallyproven.Insummary,althoughofuncontestedheuristicvalue,theuniﬁedframeworkforaddictionhasbeenfoundbyseveralauthorstolackparsimonyincreatingabroadtaxonomyforaddiction(Goudieetal.,2008;LeMoal,2008)basedprincipallyonanimalstudies.Othershortcomingsincludeaneedforgreaterunity(BickelandYi,2008),afullerintegrationofPavlovianconditioningprocesses,andacknowledgingtheimportanceofaffectivepro-cesses(KiviniemiandBevins,2008;LeMoal,2008).2.3.6.NeuroanatomicalmodelAntonproposedaneuroanatomicalmodelbasedonclinicalexperience,brain-imaging,andlaboratorydatathatnonethelessshouldbeconsideredspeculativeaccordingtoAnton(1999)untilconﬁrmedbyfutureﬁndings.Morerecentresultsfromimagingstudieswillbedescribedafterthismodeltoshedlightonitshypotheses.Likemanyotherdrugs,alcoholincreasesdopaminelevelsinthenucleusaccumbens(Antonetal.,1995).Threeotherbrainregionsaresubsequentlyactivatedthroughneuronalconnections:theamygdala;thefrontalcortex,especiallytheregionwhererewardandmemoryarethoughttobelocated,thedorsallateralprefrontalcortex(DLPC);andthebasalganglia,aregioninvolvedinrepetitivethoughtandbehaviorpatterns.TheDLPCisalsostimulatedbysensoryinformation(i.e.,thesightandsmellofalcohol)fromthefrontalcortexinadditiontoaffect(i.e.,anger,stress,guilt,etc.)fromtheamygdalaandnucleusaccumbens.Thismayaccountforwhyemotionallychargedsituationsinvolvingalcoholusearestoredintomemorywithgreater‘‘incentivesalience’’orrewardvalue.TheDLPCinreturnsendsinformation(thememory)backtothenucleusaccumbensthatmaybecomemoresensitizedtofuturedrugcues,assomeinvestigatorshaveshownwithcocaine(Kalivasetal.,1998).Inaddition,theDLPCtransmitsthememorytothebasalgangliathatmayincreaseormaintainthecravingreactionbecauseofitsroleinstereotypicthinking,thusaccountingforobsessivecraving(Modelletal.,1992;Antonetal.,1995).Theorbitofrontalcortexexertscontroloverbehaviorbyevaluatinglevelsofriskandreward.ItisthoughttoinhibitimpulsivebehaviorbysendingevaluativeinformationtotheDLPC.Orbitofrontalcorteximpairment(e.g.,headtraumaorheredity)mayaccountfortheabsenceofthiscontrolandresultinhighlyimpulsivebehavior.Similarly,becausetheorbitofrontalcortexisconnectedthroughtheDLPCtothebasalganglia,itsimpairmentmaypromoteobsessive–compulsivestates(Saxenaetal.,1998).Toillustratethismodel,Antonexplainedwhathappenswhenapersonhabituallydrinkstorelieveunpleasantemotions.Alcoholandthenegativeaffectactivatetheamygdala.ThereliefofstressproducedbythealcoholisencodedintheDLPCmemorycentersandthebasalganglia.Astrongermemorytraceisthusformedbetweenstressreliefandalcoholconsumption.Later,duringaperiodofabstinence,whenencounteringastressfulsituation,theamygdalaisactivatedalongwiththeDLPCandthebasalganglia,culminatingintheexperienceofcraving.Theneuroanatomicalmodelallowsforindividualdifferences.Individualmemoriesinteractwiththejudgmentcenteroftheorbitofrontalcortexinahighlyspeciﬁcwaywhenanindividualevaluatesthelevelofriskorrewardinagivensituation(Anton,1999).2.3.7.ModelofinteroceptivedysregulationIntheirmodelofinteroceptivedysregulation,Paulusetal.(2009)haverecentlyofferedanovelconceptualizationofaddictionaddingtwoconcepts,interoceptionandalliesthesiatoatheoreticalfoundationconsistentwithconditioningmodels,allostaticdysre-gulation(KoobandLeMoal,2001)andincentivesensitization(RobinsonandBerridge,1993).Interoceptionreferstothesensationsorfeelingsgeneratedbythecentralnervoussystemthatoriginatefromtheinteriorofthebody(Paulusetal.,2009)andincludestheinitiationofmotivatedactiontoregulatetheinternalstate(Craig,2009).Relatedtocraving,theinteroceptiveaspectconcernsthebodilysensationsandmotivationstouseasubstance.Theemphasisontheinternalstateisacentralfocalpointofthemodelbecauseitispresumedtohaveadirecteffectonhowindividualsrespondtodrugs.Theevaluationofastimulusisexpectedtobehighlydependentonthehomeostaticstateoftheindividual.Forexample,astrongcravingwouldbeexpectedtoariseinadrugaddictexposedtostimuliwhohadnodrugsinhisorherbloodstreamcomparedtoafterhavingtakendrugs.Conditioningtodrugcuesmayalsogenerateaninteroceptiveresponseandresultinacravingsensation.Theactivationisthoughttotakeplaceintheanteriorinsularcortexandtointegratenotonlythecurrentbodystatebutthepredictedoneaswell(PaulusandStein,2006).Theinteroceptivestateisoftenassociatedwithstrongaffectandmotivationalcomponentsandismediatedbyasetofneuralsubstrates.Forexample,theanteriorinsularcortexhasbidirectionalconnectionstotheamygdala(Jasminetal.,2003)andtheventralstriatum(ReynoldsandZahm,2005)whichisresponsiblefortheincentivemotivationalaspectsofrewardingstimuli(RobinsonandBerridge,2008).Alliesthesiareferstothepositiveornegativehedonicvalueofstimuli(i.e.,howmuchtheaddictwantsorcravesadrug)andisregulatedbyinteroceptiveprocessing.Alliesthesiainvolvestheconnectionbetweentheexternalstimulicreatingthecravingandtheinternalstateandisthuscriticallylinkedtointeroception.Themodelofinteroceptivedysregulationaccountsforthealterationininteroceptiveprocessinginaddictsbecausetheinternalstateisoutofbalanceduetoanaltered‘‘predictionerror’’.M.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623616 Predictionerrorreferstothedifferencebetweenthevalueoftheanticipatedorpredictedsensation(i.e.,thehopedforresult)andthevalueofthecurrentinteroceptivestate.Thealterationofthepredictionerrorleadstoinadequatecontrol,favoringtheuseofaddictivesubstances(Paulusetal.,2009).WehaveseenasimilarmechanismintheconceptofallostasisfromKoobandLeMoal’smodel.Theauthorshypothesizedthattheinsularcortexfunctionisdysregulatedinthedrugaddicted.Inanormalbrain,theinsularcortexrelaysinformationtotheotherbrainsystemstomobilizetheactionnecessarytostabilizethestate(Craig,2007)byminimizingthebodypredictionerror.Intheaddictedbrain,however,theinadequateinsularcortexfunctionresultsinaninsufﬁcientornon-adaptiveadjustmentofthebodypredictionerror,probablyduetoallostaticdysregulation,astateofchronicdeviationofthebrain’srewardsetpoint,thoughttobeattheheartoftheaddictiveprocess.2.4.FindingsfromneuroimagingstudiesandcravingNeuroimagingstudiesofthebrainduringcueexposureorafteradoseofthesubstancetoosmalltocauseapharmacologicaleffecthavevisuallyshowntheunderlyingneurobiologyofsubjectivecraving.Onthewhole,Anton’smodelhasbeengenerallysupported,butmanyquestionsremainunanswered.Mostresearchershavechosentostudycocaineratherthanalcoholbecauseitisconsideredtobeoneofthemostreinforcingofthedrugsofabuse.Onestudyconcludedthatalcoholcuesdonoteliciteffectspowerfulenoughtobedetectedbyfunctionalimagingstudiescomparedtoothersubstancessuchascocaineandopiates(Lingford-Hughesetal.,2006).Thishasbeenacommonpatterninalcoholcueexposurestudiescomparedtothoseusingdrugs.Nodeﬁnitivemodelofbrainregionsinvolvedincravinghasyetbeendetermined,althoughstrongevidencepointstotheinsulacortexastheneuralsubstrateunderlyingcravingincigarettesmoking(Naqvietal.,2007).Inthisstudy,patientswhosmokedwereexaminedbothbeforeandafterbraindamage.Thosewithdamagetotheinsulaweretwiceaslikelytoquitsmokingandalmostallofthemquiteasilyandwithoutcravingcomparedtothosewithnoninsuladamage.Ofthosewithnoninsuladamagewhoquitsmoking,threequartersreportedurges,subjectivedifﬁculty,andoccasionalrelapses.GrayandCritchley(2007)suggestedthatthebraincircuitsmediatinginteroceptioncontrib-utetocravingstates.Neuroimaginghasshownthattherightanteriorinsulaisimplicatedintherepresentationsoffeelings(Craig,2002,2009;Critchley,2005).Forareviewofactivationoftheanteriorinsularcortexinresponsetovariousinteroceptivestatesduringneuroimaging,seeCraig(2009).WhentheinsularegionofthesmokerswasdamagedintheNaqvietal.study,thesmokerswereprobablynolongerabletorepresenttheinterocep-tivesignalsofanxietyandtensioninresponsetocuesandthusunabletorespondtothemwithincreasedurgestosmoke(GrayandCritchley,2007).WhattheimagingstudieshaveﬁrmlyestablishedaccordingtoFowleretal.(2007)isthat‘‘drugaddictionisadiseaseofthebrain,causingimportantderangementsinmanyareas,includingpath-waysaffectingrewardandcognition’’(p.14)(Fowleretal.,2007).Earlystudieshaveshownthattheregionsactivatedregularly,butnotsystematicallyduringalcoholanddrugcravingwere:thecaudatenucleus,thethalamus,theanteriorcingulatecortex,theorbitalcortex,theamygdala,andthedorsolateralfrontalcortex(Hommer,1999).ThreeoftheseregionswereproposedintheinitialmodelofneuralsystemsrelatedtocravingproposedbyModelletal.(1990),thecaudatenucleus,thethalamus,andtheorbitofrontalcortex.Theseinvestigatorshadobservedasimilarityintheemotionsreportedbypatientswithobsessive–compulsivedisorder(OCD)andthoseofpatientsinacravingstate.TheythushypothesizedthatbecauseOCDseemedtobeassociatedwithadysfunctionintheorbitalcortex,perhapsthesamedysfunctionoccurredincravingsituations.Thedysfunctionwasthoughttooccurinthestriatal–thalamocorticalloopinvolvingtheorbitalcortexandservingthepurposeofreceivinginputfromthecortexinordertoactivatesmallcorticalregionswhiledeactivatingothers(Modelletal.,1990).Damagetotheorbitalcortexcanresultinantisocialbehaviorbecauseofanincapacityofinhibitingactionsthatareinappropriatetotheperson’scontext.Similarly,ifcravingisseenasaproblemoftheinhibitionofinappropriatebehavior,itcouldbeaffectedbythesamebiologicalstructures(Hommer,1999).Damagetotheorbitofrontalcontexoranteriorcingulateregionshasbeenshowntoreduceautonomicresponsivitytomotivationalcues(Bechara,2004).Orbitofrontaldamage,howev-er,wasnotassociatedwithadisruptionofsmokingaddiction(Naqvietal.,2007),whereasinsuladamagewasassociatedaspreviouslymentioned.Thiswouldimplytheexistenceoffunctionalanatomicdissociationsbetweenthetwoprocessesofinhibitinghabitualbehaviorandformingmentalrepresentationsoffeelingssuchascraving(GrayandCritchley,2007).AwelldesignedandoneofthelargestfMRIstudies(n=31)comparedcocaineabusers(n=17)withnonusersandtheirreactionswhilewatchingﬁlmsofthreedifferenttypesofcontent,oneofwhichshowedpeoplesmokingcrackcocaine.Thirteenregionswereanalyzed.Theinvestigatorswereabletoidentifyactivationofcravingsitesinthecocainegroupduringcraving.Althoughthedistinctionbetweenthegroupsdemonstratedthatlearnedcocainecuesproducebrainactivationtoagreaterextentincocaineabusersthaninhealthysubjects,thisactivationwascomparabletothatexperiencedbyhealthycomparisonsubjectsexposedtonon-drugcontentﬁlms,indicatingthatthecocaineabuserswerenolongersensitivetomildersourcesofpleasure.Theinvestigatorsconcludedthatcocainecuesaswellasnaturalstimuliactivatedsimilarneuroanatomicalsubstratesinthecocaineabuser.Cocainecravingwasthusnotassociatedwithauniqueneuroanatomicalcircuitry(Garavanetal.,2000).TheresultsfromtheGaravanetal.(2000)studysupportedKoobandLeMoal’shypothesesregardingallostasis.KoobandLeMoal(1997,2001)suggestedthattherewardthresholdinthebrainofadruguserbecomeschronicallyelevatedbecauseofprolongedexposuretointensedrugrewardsandmaynotreturntobaselinewithabstinence,leadingtoanhedonia.Alongthesamelines,usingpsychophysiologicalratherthanimagingmeasures,astudywithheroinusersshowedadecreasedresponsivenesstopleasantpicturescomparedtocontrolswhileratingtheopiate-relatedpicturesasmorepleasantandarousing.Furthermore,thesubjectiveratingsofpleasantpictures(naturalrewards)byheroinuserspredictedlaterheroinuse.Theseresultssuggesttheroleofanhedoniainaddiction(Lubmanetal.,2009).OneexplanationfortheinabilitytoexperiencepleasurefornaturalrewardsmayinvolvedecreasesinthedopamineD2receptors(DAD2)intheaddicted.DAD2receptorstransmitthereinforcingeffectsofdrugsofabuse.ThisdecreaseisdurableandhasconsistentlybeenrevealedbyPETstudiesthatcomparedaddictedsubjectstocontrols(VolkowandFowler,2000).Asaconsequence,drug-andalcohol-dependentpeoplemaybeatriskofseekingtoactivatethesedesensitizedrewardcircuitsby‘‘self-medication’’(Volkowetal.,2004),possiblyinstigatedbycraving.Thecravingprocessmaythusbeseenasaninvoluntarydesiretoactivaterewardcircuitsinresponsetodrugoralcoholcues.Drugshavebeendescribedasusurpingnormallearningcircuitrybecausetheyfortifylearneddrugassociatedbehaviorswhilereducingtheresponsetonaturalrewards(KalivasandO’Brien,2008).Overall,theﬁndingsfromneuroimagingstudiesandaddictivesubstancesdemonstratedtheactivationofseveralbrainstructuresM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623617 relatedtocraving.Researchhasshownanassociationbetweentherightanteriorinsularcortexandinteroceptiveprocessesthatunderliecraving(Craig,2007,2009;GrayandCritchley,2007).ParallelshavebeenseenbetweenactivationduringsubjectivecravinginthechronicallyaddictedandthatseeninOCDpatients,conﬁrmingthestructurallinkbetweencravingandOCD.Anotherthemeconcernedwhethernaturalstimuliactivatethesameregionsasthoseactivatedbycravingcuesandtheroleofanhedonia.2.5.MotivationalmodelsPresentedherearethreemotivationalmodelsbehindaddictivebehaviorinwhichcravingplaysamajorrole:themotivationmodelofalcoholuse(CoxandKlinger,1988),themultidimensionalambivalencemodel(Breineretal.,1999),andprimetheory(West,2006)(seeTable4).2.5.1.MotivationalmodelofalcoholuseThemotivationalmodelofalcoholuse(CoxandKlinger,1988)holdsthattheﬁnalcommonpathwaytoalcoholuseismotivational.Thestrengthofthemotivationtodrinkisassumedtobetiedtotheemotionalstateonewishestoachieve.Forexample,inasituationelicitingadesiretodrink,apersonwilldecidebasedonhisorherdegreeofincentivemotivation,thatis,thecommitmenttothepursuitofthisorothergoalsatthatmoment.IncentivemotivationasaconceptwasﬁrstpresentedbyHullreferringtothevigorandintensityofbehavior(Hull,1951).Fordrinkingtooccur,positiveaffectiveoutcomesexpectedfromdrinkingmustoutweighthoseexpectedfromnotdrinking.Ifconsumed,alcoholwillaffectmotivationintwoareas:chemicallybyalteringmoodorindirectlybybringingaboutaffectivechangesinotherareas,suchasobtainingpeerapproval.Insum,theCoxandKlingermotivationmodelplacesdrinkingbehaviorinaframeworkofmotivationtheorytherebyentailingchoice,aperspectivesimilartotheincentiveconditioningmodel(Stewartetal.,1984)inthatthechoiceisbasedonthehopeofincreasingpositiveaffect.Itdistinguishesitselffromthecondi-tionedwithdrawalmodelsinthattheemphasisisoncognitiveprocessesratherthanbiologicaldrivesorneeds.Themodeliscomprehensiveandtakesintoaccountpersonality,historicalfactors,directchemicaleffects,pastreinforcementfromdrinking,situationalfactors,andexpectancies.CoxandKlingerprovideacoherentexplanationforhowonemakesadecision.Themodelaccountslesswellfortheirrationalaspectsofcravinginthealcoholdependent.2.5.2.MultidimensionalambivalencemodelThemultidimensionalambivalencemodel(Breineretal.,1999)waspublishedalittleover10yearslaterandcanbeconsideredanupdated,streamlinedversionoftheCoxandKlingermodelthathighlyinﬂuencedtheirwork.Itconsistsoftwoparallel,motiva-tionalpathways,approachandavoidanceandaddsan‘‘evaluativespace’’wherethesecompetingmotivesintersect.Inaddition,itaddsthekeymodulator‘‘accesstoalternativevaluedactivities’’.Rootedinthebehavioraltheoryofchoice(VuchinichandTucker,1998),themodelsuggeststheexistenceoftwocerebralsystems,onethatisfavorable,inducingacraving,andtheotherthatissensitivetothreatsandthusactsasabrakeoncraving.Whenexposedtoalcohol,theindividualdetermineshisorherresponseinthe‘‘evaluativespace’’.LiketheCoxandKlingermodel,themodulatorsofthechoicetoapproachortoavoidalcoholfallintocategoriesconsistingofhistoricalfactors(e.g.,biologicalreactivitytoalcohol,personality,socioculturalenvironment,andpastreinforcement)andcurrentfactors(e.g.,quantityandqualityofpositiveandnegativeincentivesandaccesstoalternativevaluedactivities).Thesefactorscouldhaveanimpactonpeople’schoicetodrinkbycreatingnegativeorpositiveexpectanciesthatinturnpromoteavoidanceorapproachbehaviorrespectively.Thenotionoftimeanddistancearealsohighlyinﬂuentialindecisionmakingofthiskindbecausethebeneﬁtsofnotdrinkingseemparticularlydistantwhenchoicesaremade(VuchinichandTucker,1998).Furthermore,ifaccesstoalternativeagreeableactivitiesrequiresplanningandmoreeffort,thechoicewillprobablybemadeinthedirectionofdrinking.Intheevaluativespace,whereapproachandavoidancetendenciesintersect,foursubgroupscanbefound:approach,avoidance,indifference,andambivalence.Theapproachandavoidancequadrantsareself-explanatory.IndifferenceconsistsTable4Motivationalmodels.Basicpremise:cravingisacomponentofalargerdecision-makingframework.ModelSubstanceKeyﬁguresImplicationforcravingTriggerKeyhypothesesMotivationalmodelofalcoholuseAlcoholCox,KlingerMotivationtodrinkcanbethoughtofastheforceofdesireorurgetodrinkanddependsuponthedegreeofincentivemotivation(i.e.,commitmenttopursueagoal).ItwillﬂuctuatebasedontheexpectationsonehasastotheeffectthatdrinkingwillhaveonaffectExpectationsTheﬁnalcommonpathwaytoalcoholuseismotivational.Motivationtodrinkisassumedtobetiedtotheemotionalstateonewishestoachieve.OnemaynotbeawareofthedecisiontodrinkorthefactorsthataffectthisdecisionPhysiologicalneeds(drives)DesiretochangeaffectMemoriesofpastreinforcementfromdrinkingMultidimensionalambivalencemodelAlcohol,cocaineBreiner,Stritzke,LangCravingandaversion(orapproachandavoidance)formtwopathwaysthatrepresentcompetingbrainsystemsthatrespondindependentlytovariousmodulatorsMultifactorialvariablesinﬂuencecravingandaversion,forexample:biologicalreactivity,personalitystyle,socioculturalnorms,positiveexpectancies,accesstovaluablealternativeactivities,andpresenceofcuesAcentralcharacteristicofaddictionisambivalencewhichoccurswhenapproach(craving)andavoidance(aversion)arebothhighPrimetheoryAddictivesubstancesWestCravingisapartofthemotivationalstructureattwolevels:impulses/inhibitionsandmotives.PowerfuldrivesresultfromadisturbanceofthemotivationalstructurethathasbeenmodiﬁedbythesubstanceEnvironmentalcuesNewthemesthatmodulatecravingare:focusonthemoment,neuralplasticity,importanceofidentity,andtheunstablemind.Patternsofdominanceexistinthemotivationalstructure:impulsesoverrulemotives,motivesoverruleevaluations,andevaluationsoverruleplansExpectanciesAssociativelearning(conditioning)EmotionaldisturbanceSensitizationofthebrainMoment-to-momentcircumstancesM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623618 oflowapproachandlowavoidance,whereasambivalenceconsistsofhighapproachandhighavoidance.InacocainestudybyAvantsetal.,69participantsevaluatedonseparatescalesapproachandavoidanceinclinationsafterviewingaﬁlmofcocaineuseandhandlingcocaineparaphernalia.Evidencewasfoundsuggestingthatoverallcravingandaversionratingsvaryindependently.Atbaselinewheretherewerenocues,thetworatingswerenegativelycorrelated,whereasafterexposuretocues,therewerenosigniﬁcantcorrelations(Avantsetal.,1995).Thisstudythussupportedthehypothesisthatapproachandavoidance(orcravingandaversion)weretwodimensionscapableofindependentvariationwithcocainecues.Moreresearchisneededtoextendtheseﬁndingstootheraddictions.Anotherstudywithconsumablesubstancesdemonstratedanegativecorrelationbetweencravingandaversioninabstainers,butamonglightandmoderatedrinkersandsmokers,nosigniﬁcantcorrelationswerefound(Breineretal.,1997).Otherevidenceexiststosupportthemodelinastudyoftheviewingofappetizingfoodslides(Stritzkeetal.,1997)andwithmemoryprocessesandalcoholuse(LeighandStacy,1998).Boththemotivationmodelofalcoholuseandthemultidimen-sionalambivalencemodelpresumethatwhenasituationprovokesadesireorcravingtodrink,modulatorswillaffectthedecisionprocessofwhetherornottodrink.Theyincorporatetwopathways:whethertoindulge,theapproachpathway,ortorefrain,theavoidancepathway.Akeyassumptionisthatcravingwouldinclineanindividualtoapproachalcoholifnotmodulatedbyotherfactors.Whatdistinguishesthesemodelsfromthosepresentedpreviouslyisthecentralroleofambivalence.Breineretal.pointedoutthattheearlyconditioningmodelsofcravingaswellastheneuroadaptivemodelofRobinsonandBerridgehadfocusedexclusivelyonapproachinclinations.Thequestionsaboutwhatliesbehindavoidanceinclinations,however,wereleftunan-swered.Previousmodelshadnotbeenabletojustifywhysomedependentindividualsget‘‘stuck’’inambivalenceastheyweighthevariousfactorsthatinﬂuencethedecisionofwhetherornottodrink.CompetingmotivesandambivalencearefundamentalfeaturesofthecriteriaforsubstancedependenceasnotedintheDSMIV(Breineretal.,1999).Forexample,criteria3,4,and7illustratetheinternalconﬂictofbeingbothdrawntoandrepelledbyalcohol:‘‘thesubstanceisoftentakeninlargeramountsoroveralongerperiodthanwasintended’’,‘‘thereisapersistentdesireorunsuccessfuleffortstocutdownorcontrolsubstanceuse’’,‘‘thesubstanceuseiscontinueddespiteknowledgeofhavingapersistentorrecurrentphysicalorpsychologicalproblemthatislikelytohavebeencausedorexacerbatedbythesubstance’’(AmericanPsychiatricAssociation,1994)(p.181).Inherentinthecravingphenomenonistheconﬂictbetweenthedesiretoconsumeopposedbythedesiretoremainabstinent.Infact,Tiffany(1999)pointedoutthatitisjustthisobstacleofself-restraintthatmayamplifythecraving.Whatliesbehindthisself-restraint?AccordingtoLang(1995),a‘‘brakingsystem’’underliesavoidancethatissensitivetothreatsandothernegativestimulisuchasfear,sickness,oranxiety.Thisaversivesystem,thebehavioralinhibitionsystem(BIS),opposesthebehaviorappetitivesystem(BAS).Thetwohaveimportantstructuresincommonsuchastheamygdalaandtheprefrontalcortexbutarethoughttobeseparatesystemsandmutuallyinhibitory(Lang,1995).Alcoholcanactivatebothsystemsbutatdifferentsites.Forexample,Gray(1982)foundthatalcoholcandecreasetheactivityoftheBISsystemwhileincreasingtheactivityoftheBASbycausingdopaminerelease.2.5.3.PrimetheoryAsynthetictheoryofmotivationforaddictivebehaviorhasbeenproposedbyWest(2006)thatseekstoexplainbehaviorbytakingintoaccountphenomenasuchasimpulses,drives,experi-ence,learning,habits,urges,choice,andnorms.Fivethemesdeﬁnethetheory:thestructureofthemotivationalsystem,thefocusonthemoment,neuralplasticity,theimportanceofidentity,andtheunstablemind.Theﬁrsttheme,thestructureofthemotivationalsystem,isdescribedbytheacronymPRIMEsignifyingplans,responses,impulses/inhibitingforces,motives,andevaluations.Plansareatthehighestlevelofcomplexityinthemodelandconcernmentalrepresentationsofwhattodo,theactionsnecessary,andcommitment.Plansonlyinﬂuenceresponseiftheycanmobilizeaction.Aplanisuseless,forexample,ifanattractivestimulusincitesacompetingandmorepowerfuldesire,foritisoverridden.Inaddition,aplanisonlyusefulifitisrememberedandpowerfuldesiressuchascravingsmayinterferewithrecall.Thelowestlevelofthemodelisresponsereferringtostarting,stopping,ormodifyingactions.Thenextlevelofcomplexityconcernsimpulsesandinhibitoryforceswhichdrivebehaviorinthemomentandaregeneratedbyexternalstimuli(e.g.,environmentalcues)orinternalstimuli(e.g.,desiresatthetime).Anirrepressibleurgewouldﬁtintothislevel(e.g.,theurgetoscratchanitchorsatisfyacraving).Importanttonoteisthepowerofimpulsesandinhibitoryforcestooverrideallotherlevelsofthestructureofthemotivationalsystem.Nextincomplexityaremotiveswhicharedesiresandwantsthatevenifunconsciousmayinﬂuencebehaviorbycreatingimpulsesandinhibitionstofulﬁllanimaginedfuturestate.Whenthefuturestatecannotbeimmediatelymet,anindividualwillformaplan.Evaluationsareatthenextlevelandincludebeliefsaboutwhatisconsideredtobeagoodthingtodoatagiventime(e.g.,whatisuseful,detrimental,right,orwrong).Evaluationsmustbeinagreementwithmotivesandimpulsesrespectivelytohaveaneffectonbehavior.Thesecondtheme,focusonthemoment,referstothemoment-to-momentresponsesthatarecontinuallysubjecttocompetingimpulsesandinhibitoryforces.Becausemotivationandbehaviorarethoughttobeﬂuidanddynamic,theycanonlybeinﬂuencedbypresentforces.Forexample,onemustbeengagedinaplantouseitandrememberabelieftoenactit.Thisconceptexplainswhyanunexpectedurgeordesirecanoverrideaplan.Neuralplasticityisthethirdtheme,referringtothechangesthatoccurinthemotivationalsystemasaresultofone’sexperiences.Therearethreetypesofplasticity:sensitization/habituation,explicitmemory,andassociativeorconditionedlearning.Thefourththeme,identity,isdeﬁnedashowpeopleperceivethemselvesandhowtheywanttobe.Includedinthethemeofidentityisself-awarenessanditseffectonself-control.Feelinggoodordisappointedinoneselfwillaffectself-directedattentionaswellastheformulationandadherencetoplans.Forexample,whenpeoplefeeldespair,theyareunlikelytocareaboutself-control.Theﬁnalthemeistheconceptoftheunstablemindandreferstothenecessityofcontinuallybalancingthemindbyusingstabilizingfactorssuchasothersourcesofcontentment.WestexplainedtheprocessusingWaddington’s(1977)epigeneticlandscape.Aballisatthetopofahillylandscapewithmultiplepathwaysdescending.Aminorchangeoreventatacriticalmomentmayproduceasuddenshiftinthedirectionoftheball(i.e.,one’slife)inaseeminglyunpredictablemanner,shiftingthedirectionoftheballtoanotherpath.Conceptstakenfromchaostheoryexplaininasystematicmannerwhatseemstobeunpredictablebehavior.Howdoescravingﬁtintoprimetheory?Whenpeoplebecomeaddicted,themotivationalsystembecomesdisordered.Asaconsequence,theurgetoapproachthedesiredproductbecomesapriority.Appearingatvariouslevelsofintensity,theurgecanrangefromjustadesireforapleasurableexperiencetoanoverwhelmingcraving.Ifthecravingislimitedtoadesireforthepleasanttasteofasubstance,itwouldﬁnditsplaceinthe‘‘motives’’levelasaM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623619 hedonicfeelingofliking.Atitsmostintensestate,cravingwouldoccuratthelevelofimpulses/inhibitionasaninternaldriveoranirrepressiblereactiontoexternalstimuli.Thetheorypositsthatlowerlevelsofthemotivationalstructuremayattimesdominatehigherlevels.Forinstance,throughassociativelearning(condi-tioning),acuemightcreateanexpectancyofrelief,pleasure,orevenanegativestatesuchasfearofnegativeconsequences.Thefeelinggeneratedbytheexpectancywilldominateplans,intentions,andbeliefsandthusdeterminetheoutcome.Thepatternofdominanceisasfollows:impulsesoverrulemotives,motivesoverruleevaluations,andevaluationsoverruleplans.Whathappenswhenseveralevaluationsalongwiththeiraccompanyingemotionsareinconﬂict?Thealcoholicintreatmentwhodoesnotwantadrinkandintendstomaintainhisorherabstinencemaystillexperienceapowerfulcraving(impulse)underparticularcircumstancesandmustmaintainthedissonanceuntilthecravingpasses.Atthesemomentsofconﬂictingfeelingsandthoughts,thequestionarises:whichcourseofactionwillbringthemostcontentmentordistress?Itisasifthecountervailingforcesarekeepingtheballoftheepigeneticlandscapehesitatingatthetop.Duringthisuncomfortablephase,motivationisinlimbo.Weststatedthatthemotivethatisthestrongestatthemomentwilldeterminetheﬁnalresponse.Anyemotions,wants,needs,andenvironmentaltriggerspresentatthatmomentwillexertapowerfulinﬂuenceovertheﬁnaloutcome.Elementsfromconditioning,cognitive,psychobiological,moti-vation,andchaosmodelsappearinprimetheory,makingitacomprehensivemodelthatexplainstheinterrelationshipsbe-tweenavarietyofphenomenaandaccountsforurgesaswellasambivalenceintheaddictionsatalllevelsofdependence.Themodelisparsimoniouswithclearlydeﬁnedandpreciseconstructs.Whatremainstobeaccomplishedisthevalidationofhypothesesgeneratedbythismodel.Aparticularchallengewillbeselectingorcreatingnewmeasurementmethodstoevaluatetheseinterrela-tionships.3.SummaryandconclusionsThefoundationofcue–reactivityresearchbeganwithclassicalconditioningexplanationsofcravingasabiologicaldriveprovokedbywithdrawalsymptomsorcues.Speciﬁcclinicalortheoreticalgoalsinspiredbythesemodelsledinvestigatorstoanexpandedunderstandingofcravingwithafocusoncognitivecomponents.Tiffany’sideaofcravingasbeingeffortful,requiringcognitiveresourcesandarisingwhenconfrontedwithanobstacle,explainedtheambivalencethatsomanypatientsfaceduringtreatment.ItalsoresonatedwiththeBreineretal.’smultidimensionalambivalencemodelbecausethesimultaneouswantingandavoidingofsomethingisastateofambivalenceconsistingofhighapproachandhighavoidanceinclinations.Inothermodels,cognitiveprocesseswereattimessubjugatedbythephysicaldimension,asdemonstratedbythepsychobiologicalmodels.Thesemodelsfocusedon:neuroanatomy(Anton,1999),individualdifferencesinneurotransmittersystems(Verheuletal.,1999),incentivesalienceandthedistinctionbetween‘‘wanting’’and‘‘liking’’(RobinsonandBerridge,1993;BerridgeandRobinson,2003),allostasisandtheantirewardsystem(KoobandLeMoal,2008)valuesignalsandvulnerabilitiesindecision-making(Redish,2004;Redishetal.,2008),andthebodypredictionerror(Paulusetal.,2009).Theyprovidedaframeworkforunderstandingtheinherentlyirrationalandunpredictablesideofaddiction.ThispointwasexpandedinprimetheoryinWest’sdescriptionoftheunstablemindandthedisturbanceswithinthemotivationalstructure.Neuroimagingtechniquescontributedvisualevidenceofactivityinthemidbrainstructuresthatwasattimescorrelatedwithsubjectivecraving,supportingthephysiologicalbasisofcraving.Thefactthatthetwowerenotsystematicallycorrelatedsuggestedthateithercravingwasunconsciousorthatothercognitiveprocesseswereevokedbythestimuli.Themotivationalmodelshelpedtomakeprogressonthepuzzlesofcravingbyincorporatingconditioning,cognitiveprocesses,emotions,physi-ology,andpsychologyintocomprehensiveaddictionmodels.Baseduponthisamassedknowledge,howmightwenowreformulateadeﬁnitionofcraving?Weproposeadeﬁnitionofcravingspeciﬁcallyforabstinentalcoholandotherdrugusersasadesireofanyintensitytoconsumeasubstance.Thisdesirecreatesanimbalance(e.g.,anxiety,cognitivedissonance,irritability)ifrepressed,dueinparttoanalterationofthebrainandneurotransmitterfunction(sensitizationandallostasis)resultingfrompriorsubstanceuse.Cravingisillogical,requiringcognitiveresourcestomanageandisthuseffortful,modifyingattention,memory(especiallyretrieval),perception,andconcentration,althoughthesechangesareoftenimperceptibletotheindividual.Similarly,theremaybeautonomousreactions(e.g.,increasesinsalivation,skinconductance,heartrate,bloodpressure,andactivationofspeciﬁcbrainstructures)thatmayormaynotbedetectedfortheydependontheinteroceptivecapacitiesoftheindividual,hisorherhomeostaticlevel,theintensityofthedesire,andthetypeofsubstance.Cravinggenerallysetsinmotionastrongmotivation,akintoanobsession,todowhatisthoughtnecessarytorelieveit.Itcanarisetoescapeaversivestates(reducediscomfort)andtoincreaseagreeablestates.Bothcravingandurgeshouldbeusedinterchangeablytorefertothedesiretoconsume,ifonlytoavoidfurthertimelossindefendingpositions.Takingintoconsiderationthecravingtheoryliterature,weexamineheresomeoftheimplicationsfortreatment.Caneachcravingproﬁlebematchedtoatreatment?Toadegree,yes.Forexample,Marlatt(1990)suggestedthatpositiveexpectanciesbehindcravingbeopposedbymorerealisticnegativeexpectanciesoflong-termuseandproposedcombiningcueexposurewithcopingskillstraininginactualhigh-risksituationsandinthepresenceofdrugcues.Likewise,Bakeretal.(2004)considerednegativeaffecttobethefocalpointofthewithdrawalsyndromeandthereforethetreatmentfocusmustbeonsuppressingnegativeaffect.Itmustbekeptinmindthatnoonetypeofinterventionisexclusivelyassociatedwithaparticulartheory.Treatmentinter-ventionscanbedividedintotwobroadtypes,thosethatarepsychotherapeuticandthosethatarepharmacologicalandtheyarenotmutuallyexclusive.Thepsychotherapeuticinterventionsarenumerousandmaybeusedindifferentcombinations.Someexamplesarecognitivebehaviortherapy,cueexposuretherapy,relaxationtraining,mindfulness-basedtherapy,contingencymanagementtherapy,andmotivationalinterviewing.Further-more,itisalsowidelyrecognizedthattheaddictionproblemmustbytreatedfromallangles,includingmedical,vocational,psychiatric,familial,andsocialneeds.Thepharmacologicalapproachesattempttoreduceorblockthedrugreward(e.g.,naltrexone),toreducecraving(e.g.,acamprosateandnaltrexone),toreducediscomfortfromwithdrawal(e.g.,methadoneandbuprenorphine),orcreateanaversivereactionifalcoholisconsumed(e.g.,disulﬁram).Thesepharmacologicalapproachesshouldbeideallyusedasanadjunctivetocognitivebehaviortherapy,fortheywillnotcureaddictionandrelapsetodrinkingisprobablewhentheyarestopped(O’Brien,2008).Oneaspectofcravingthathasnotbeensufﬁcientlystudiediswhatturnsitoff–ortheaversiontreatments.TheworkofBreineretal.(1999)andCoxandKlinger(1988)demonstratedtheimportanceoftakingintoaccounttheavoidancedimension.Traditionally,treatmentstrategiesfocusedmoreonreducingcravingthanonincreasingtheaversionofaddictivesubstances.Westilldonotknowmuchabouthowtreatmentsthatincreaseavoidance(asopposedtodecreasingdesire)ofaddictivesubstanceswouldinteractwithM.D.Skinner,H.-J.Aubin/NeuroscienceandBiobehavioralReviews34(2010)606–623620 negativeaffect.Thisisimportantbecausenegativeaffectiswidelyacceptedasavulnerabilityforrelapse.Anaversivepharmacologicalapproachthathasbeeninsufﬁ-cientlystudiedinrelationtocravingistreatmentwithdisulﬁram.Inacueexposurestudyinourlaboratory,wefoundthatalcohol-dependentpatientsintreatmentwhobelievedtheyhadtakendisulﬁramrespondedtothesightandsmelloftheirfavoritealcoholicdrinkwithadecreasedphysiologicalresponse(i.e.,lowerbloodpressure)comparedtothosewhobelievedtheyhadtakenaplacebo(Skinneretal.,2009).Therewasnochangeinthesubjectiveresponse.Furtherresearchisnecessarytounderstandtherelationshipbetweendisulﬁramandthephysiologicalaswellasthepsychologicalresponsetocues,notablytheeffectofapotentialdisulﬁramethanolreactionondecision-making,atten-tion,affect,andcognitivedissonance.Contingencymanagementisaparticularlysuccessfultreatmentapproachbasedonoperantconditioningtheoryprovidingreinforcementforabstinencebyawardingvouchersofsmallmonetaryvalueforgoodsandservices(KaddenandCooney,2007).Severalstudieshaveshownthatthisapproachhasresultedinbettertreatmentattendanceandimprovedabstinenceratesortimetorelapse(Iguchietal.,1997;Petryetal.,2000;Dutraetal.,2008;StitzerandVandrey,2008).Theattractiontovouchersmaybeexplainedbytheactivationofadifferentdecision-makingprocessfromtheoneinvolvedindruguse–perhapsonethatislesssensitivetocost.Thefactthatthereisaforceddecisionwithexplicitalternatechoicesmayhelpsomeaddictsremainabstinent(Redishetal.,2008).Itispossiblethatthecompetingmonetaryreward,althoughsmall,shiftsattentionawayfromtheﬁxationonacravingtargettowardthevoucher,thusallowingtheelaborationofthoughtsfocusedonanon-cravingobject,themoney.Futurestudiesareneededtofurtherexplorethemechanismsbehindtheseﬁndings.Interferenceofthissortmayimpedecraving(Kavanaghetal.,2005;Mayetal.,2008)assuggestedbyelaboratedintrusiontheorybyKavanaghetal.(2006)whichemphasizestheroleofintrusivethoughtsoncraving.Perhapsthemostprominenttreatmentimplicationthatemergesfromthecravingliteratureistheimportanceofmatchingtreatmenttoindividualneeds.OneexampleissuggestedbyRedishetal.intheiruniﬁedframeworkforaddictionmodel.Thechallengewastoidentifywhichofthe10vulnerabilitiesthepatientmanifestedandthenmatchthetreatmenttothoseneeds.Forthishypothesistobetested,anevaluationinstrumentwillneedtobedeveloped(Redishetal.,2008).AnothermatchingexampleisprovidedbyAddoloratoetal.BasedonthethreetypesofcravingproposedbyVerheuletal.(1999),Addoloratoetal.(2005)proposednaltrexoneandGHB(gamma-hydroxybutyricacid)forrewardcraving;acamprosate,GHB,andbaclofenforreliefcraving;andselectiveserotoninreuptakeinhibitors(SSRI),baclofen,topiramate,andodansetronforobsessivecraving.ResearchbyOotemanetal.revealeddifferentmechanismsofactionforanticravingmedications.Theycomparednaltrexonetoacampro-sateinalcoholicsandfoundthatacamprosateactedmoreonphysiologicalcuereactivity(heartrateandskinconductance),whereasnaltrexoneactedmoreonsubjectivecraving(Ootemanetal.,2007).Treatmentimplicationsfromtheseﬁndingssuggestthatacamprosatemightbemoreeffectiveforthosepatientswhoexpresscravingautonomicallyasopposedtonaltrexonewhichmaybeabettermatchforthosewhoexpresscravingsubjectively.Thesehypotheseshaveyettobeconﬁrmed.Insum,wehavereviewedtheunfoldingofcravingconceptswithin18modelsthatspanroughly60years.Theamassedevidencesuggeststhatcravingisanindispensableconstruct,usefulasaresearchareabecauseithascontinuedtoperturbanddestabilizemanypatientsseekingtreatmentforsubstances.Theformulationofthevariousmodelshashelpedusnotonlytoorganizedatabutalsotomakerealprogressonclarifyingthemysteriesofaddictionanditstreatmentbygeneratingquestionsthatstimulatecontinualinvestigation.Thiswouldnothavebeenpossiblewithouttheconstruct.AcknowledgementsThisresearchwassupportedinpartbygrantsfromtheDepartmentofClinicalResearchandDevelopment,AssistancePublique-HoˆpitauxdeParis(CIRC05131)andfromtheInstitutdeRecherchesScientiﬁquessurlesBoissons(IREB-InstituteofScientiﬁcResearchonDrinks).Inaddition,thispaperisbasedonresearchforadoctoraldissertationwithalcohol-dependentpatientsthatfocusesontherelationshipofathreattoalcoholcravingusingacueexposureparadigminaFrenchhospital.Weconﬁrmthatthereisnoconﬂictofinterest.ReferencesAddolorato,G.,Abenavoli,L.,Leggio,L.,Gasbarrini,G.,2005.Howmanycravings?Pharmacologicalaspectsofcravingtreatmentinalcoholaddiction:areview.Neuropsychobiology51,59–66.AmericanPsychiatricAssociation,1994.Diagnosticandstatisticalmanualofmentaldisorders.AmericanPsychiatricAssociation,Washington,DC.Anton,R.,1999.Whatiscraving:modelsandimplicationsfortreatment.AlcoholResHealth23,165–173.Anton,R.,Moak,D.,Latham,P.,1995.TheObsessiveCompulsiveDrinkingScale(OCDS):anewmethodofassessingoutcomeinalcoholismtreatmentstudies.ArchGenPsychiatry53,225–231.Aston-Jones,G.,Delfs,J.M.,Druhan,J.,Zhu,Y.,1999.Thebednucleusofthestriaterminalis.Atargetsitefornoradrenergicactionsinopiatewithdrawal.AnnNYAcadSci877,486–498.Avants,S.,Margolin,A.,Kosten,T.,Cooney,N.,1995.Differencesbetweenrespon-dersandnonresponderstococainecuesinthelaboratory.AddBehav20,215–224.Baker,T.,Morse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Topic 8 DQ 1 - 2/10/23 Assume you are working at an agency with both inpatient and outpatient services. Mary is a client of yours in inpatient so you will be working with her one-on-one at least once a week in inpatient treatment then she will transfer levels (from Level III to Level II) at which point you will also be her counselor in intensive outpatient. Based on Chapter 8 and your knowledge of clinical interventions, how could you integrate specific counseling interventions (such as CBT, MI, and SF) that target triggers into both inpatient and outpatient treatment? Consider Bible-based or Christian Counseling interventions. Her diagnoses include Alcohol Use Disorder, Opiate Use Disorder, and Generalized Anxiety Disorder (GAD). Use headings: Inpatient Interventions, Outpatient Interventions. Topic 8 DQ 2 - 2/10/23 Consider coping strategies that are used in faith-based programs or organizations. How do coping strategies help clients prevent relapse? Present at least two examples of coping strategies and explain how they may benefit the client, their family, and the community in which they live and work. Topic 8: Inpatient And Outpatient Treatment Planning Capuzzi, D. & Stauffer, M. (Ed.). (2019). Foundations of addictions counseling (4th ed.). Pearson ISBN-13: 9780135166932 Read Chapters 20 in Foundations of Addictions Counseling. Read "Chapter 4—From Precontemplation to Contemplation: Building Readiness," by Rockville (MD), from Substance Abuse and Mental Health Services Administration (US) (2019). Watch "Jailhouse Religion?," by HBO (Producer), from Films Media Group (2017). WARNING: Viewer Discretion Advised The consumption of illegal substances is discussed or depicted in this video. Some language in this video may be offensive. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution. Copyright American Psychological Association. Not for further distribution.

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