NCAD East | Recognizing the 4 Types of Cravings in SUD Patients

In 2015, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) added cravings among the criteria for substance use disorders (SUDs), a key development for the field of SUD treatment.

On Saturday at the National Conference on Addiction Disorders East in Baltimore, Doug Paul, LPC, CPCS, LMHC, QS, a private practitioner based in Atlanta, discussed the implications for the inclusion of cravings in the DSM-5, and categorized 4 types of cravings observed in SUD patients.

In a recent email exchange with Addiction Professional, he broke down the 4 cravings types and provided real-world examples of each.

In what ways have the addition of cravings to the DSM-5 impacted how SUD is identified and treated?

Doug Paul: A few of years ago now, in 2013, when the new DSM-5 came out, I was excited to learn that the drafters had included “cravings” as 1 of 11 criteria for SUDs. The DSM-5 refers to cravings as “a strong urge to use.” This seems a bit simplistic, so I would offer another definition from the Substance Abuse and Mental Health Services Administration (SAMHSA): “an urgent, seemingly overpowering desire to use a substance, which is often associated with triggers of drug use, that creates tension, anxiety, or other dysphoric, depressive, or negative affective states.”

The DSM-5 makes it clear that craving is the only criteria that continues into and past the period of post-acute withdrawal. In most cases of those who receive proper treatment, social, interpersonal, occupational, physical, and psychological issues typically resolve in the first 90 to 180 days of recovery. Craving for substances can continue well past that time.

Are there different types of cravings that providers should look for and what strategies or interventions do you recommend providers implement to help their patients manage their cravings?

DP: In Dr Paul Earley’s book, The Cocaine Recovery Book, he outlines perhaps the best description of cravings I have come across. In chapter 5, he outlines 4 types of cravings and gives detailed descriptions of each.

Reinforced use craving: Conceptually, this craving type is the easiest to understand. When substances are introduced into the body of someone with a SUD, in any amount, this craving takes hold and demands the person take more over a longer period than was intended, no matter how damaging. When the recovery literature mentions the word “craving,” this is the type they are referring to (and none of the others discussed later). In treatment, we encourage abstinence from all substances of abuse to avoid this type of craving. The concept of “cross-addiction” demonstrates that when another substance is used that an individual considers NOT to be problematic for them, there’s a greater potential for craving to result in that individual using their drug of choice. It’s that simple: once a person has ceased the use of substances of abuse, they will never again experience this type of craving.

>> WATCH an example of reinforced use craving

Overt interoceptive craving: The next type of craving occurs once substance use is ceased. It is described it as overt because the client experiences the craving directly; and it is described as interoceptive because it is triggered by sensations in the body that typically preceded substance use. In the case of the cocaine user, just before initiating cocaine use, they may report symptoms of sweaty palms, dry mouth, and gastrointestinal urgency. When these symptoms combine with something internal like normal anxiety, a spontaneous thought emerges: “I want to use.” These types of cravings are a normal occurrence in residential treatment; in fact, they are the reason that residential treatment exists.

When they occur, treatment staff are trained to help the client by reviewing an established protocol. First, they ask the client what was going on internally and emotionally just before they realized they were craving. Next, the client is asked to catalog those sensations as craving triggers for future reference. Last, the client is asked to briefly describe the craving to their therapist, therapy group, or a supportive friend, stopping short of what they would do if they had alcohol or other drugs. The client is encouraged block themselves from romanticizing what would happen if substances were available.

During the period when overt interoceptive cravings are most likely to occur, which can be between 7 and 40 days of abstinence, there are 2 phenomena that must be addressed in the treatment setting: romanticizing substances and using/drinking dreams.

>> WATCH an example of overt interoceptive craving

In Dr Earley’s book, romanticizing is described as “a self-induced elaboration in which drug use is seen as a positive experience, a grand adventure.” Memories of past substance use can trigger the brain to release small amounts of neurotransmitters, like dopamine, into the pleasure center of the brain. When romanticizing begins, other clients or friends may join the conversation and heighten the stakes by sharing stories. Before long, everyone is craving! Spontaneous cravings are difficult enough and any opportunity to avoid a self-induced craving episode is a win.

Dreams of use, regardless of the substance, are an important feature of overt interoceptive cravings because of the visceral nature where the client often feels some or all the euphoria from their substance during the dream. Not everyone will have using dreams but those that do describe them as disruptive. Typically, the client’s sleep is poor and the following day they can be distracted and unable to absorb much treatment. In this way, the craving has caused a significant deficit.

Covert craving: Dr Earley points out in his book that as overt cravings resolve, they can be replaced by covert craving. The treatment staff refers to this craving as the “I gotta go’s.” It typically involves a feeling of restlessness and irritability combined with a false sense of confidence that the client will never be tempted to use substances again. Covert craving is described as a behavioral craving, and the client usually reports an intention to remain in recovery. Instead, they are drawn out of their treatment mindset by outside issues. A client may feel the sudden need to return home to mend their lives that took years to shatter, not realizing that their distraction is very subtly placing them in jeopardy. Acting on this impulse, they attempt to leave treatment early. Anyone who endeavors to talk them out of it are pushed away with anger. Irritability is a primary symptom of covert craving. Treatment staff are trained to implement any number of interventions to prevent a client leaving treatment with the primary goal of allowing 48 to 72 hours to pass so the episode resolves. Interventions used typically reduce confrontation, engage the peer group, and honor autonomy for decision making. The paradox of the profound loss of insight secondary to advanced-stage substance use disorder and the honoring of autonomy for decision making is intentional and necessary.

>> WATCH an example of covert craving

Conditioned cue craving: The final craving type identified by Dr Earley’s book is the result of the capacity of the human brain to learn. Through evolution, the primate brain became an expert in identifying, prioritizing, and anticipating rewards in the environment consistent for survival. Through his work measuring canine saliva, Dr Pavlov named this process “classical conditioning.” For the substance use disorder client, this should be referred to as hyper-conditioning due to the sheer volume of dopamine released by substances. Nothing in our evolutionary training prepared our brains for the massive surges modern drugs release in comparison with more predictable rewards like food or sex.

Conditioned cue craving involves seemingly strange associations with things outside of substance use: people, places, sights, sounds, and smells that have become associated with substances. Clients are trained to begin making a list of those triggers so they might anticipate them if they are tripped.

In the case of the opioid user who enters withdrawal, they might describe feeling “flu-like symptoms” like runny nose, nausea, vomiting, aches, and pains, etc. The first time they get a cold in early recovery, they get triggered to return to using opioids. Why? Because in the past, these symptoms were completely extinguished using opioids.

Conditioned cue craving is an undercurrent to the other 3 craving types. It is independent on the timeline and resolves over a longer span. Just as Pavlov’s dogs eventually stopped salivating when he removed the food, clients will eventually stop associating triggers with substance use. It just takes longer than Ivan’s dogs.

>> WATCH an example of conditioned cue craving

References

Paul D. A multi-faceted approach to cravings management. Presented at: National Conference on Addiction Disorders East; November 19-21, 2021; Baltimore, MD.

Alcoholics Anonymous World Services. Alcoholics anonymous big book. 4th edition. New York, NY; Alcoholics Anonymous World Services; 2002.

Chapter 5: Craving Patterns. In: Earley PH, ed. The Cocaine Recovery Book. (p. 208). Thousand Oaks, CA: SAGE Publications; 1991:208.

Substance Abuse and Mental Health Services Administration. Addiction counseling competencies: The knowledge, skills, and attitudes of professional practice 171. Rockville, MD: US Department of Health and Human Services; 2004.