In this study we evaluated factors associated with craving among those with an SUD in an outpatient treatment setting. We found that those who reported Hispanic/Latinx ethnicity were less likely to report craving in the past 30 days. We also found that patients who reported active substance use in the past 30 days were more likely to report craving in the past 30 days. Sex, age, patient reported White race, marital status, completing college, employment, religion, ACE score, history of DUI, arrest history, and self-reported alcohol problem were not associated with craving in this sample.
The goal was to evaluate various factors that may be associated with craving to better understand the significance of reported craving in a clinical setting. This study offers new information regarding variations in craving across ethnic groups, a topic which remains incompletely understood. Understanding how race/ethnicity affects the experience of craving is crucial to providing care to minority populations that are already disproportionally underutilizing treatment services for SUD.
The observed findings show that patient who report Hispanic/Latinx ethnicity and have a SUD were overall less likely to report craving, even when accounting for recent substance use. This finding may be explained by genetic factors mediating craving response, psychosocial factors influencing report measures, or both. In patients with alcohol use disorder, variation in efficacy of naltrexone for mitigating craving among individuals of White race or African American ethnicity is thought to be attributable to a specific polymorphism(19). This suggests a possible genetic basis for difference in the experience of craving amongst varying populations (19). Polymorphisms found in other genes, such as those in the dopamine reward pathway and those encoding for protein alpha-synclein, are associated with increased craving amongst those with SUD (21–23). These genetic variations are suspected to be specific to craving and distinct from other genetic pathways underlying the SUD phenotype (22). Craving specific genetic underpinnings could therefore be responsible for the lower craving we found among patients who reported Hispanic/Latinx ethnicity. Elucidating genetic markers associated with lower levels of craving in this population can help in the development of neurobiological treatment targets for craving. As research continues to investigate the genetic basis of craving and addiction, we recommend the evaluation of how these factors vary across race and ethnicity.
Psychosocial factors leading patients who report Hispanic/Latinx ethnicity to report less craving compared to their counterparts may also explain our findings. Racial/ethnic disparities regarding substance use are well documented, particularly among Hispanic/Latinx individuals (24, 25). Prior research demonstrates that Hispanic/Latinx patients underutilize SUD treatment due to stigma (25). Latinx individuals experience higher levels of negative bias, worse social consequences, and decreased social support regarding substance use compared to patients who report White race (25–28). Furthermore, perception of low treatment efficacy likely plays a role in lower levels of craving.
Additional research is necessary to determine the primary factors responsible for this relationship, whether it be genetic or environmental. Nonetheless, it is important for clinicians to be cognizant that reports of craving can vary across ethnic groups and thus craving must be addressed appropriately and considered when evaluating patient risk for treatment discontinuation or relapse.
A large number of studies evaluate craving and future substance use, but few evaluate the relationship between craving and substance use in the 30 days preceding treatment entry. We found that those who reported any substance use in the last 30 days were significantly more likely to report craving during that same time. This finding supports our hypothesis and aligns with prior research showing craving to be positively correlated with the number of heavy drinking days, severity of alcohol dependence, and overall substance use (19). Craving reported on treatment entry thus indicates a need for evaluation of withdrawal symptoms and recent use indicates a need for craving assessment.
This study is the first known to evaluate the relationship between ACE score and craving. Past studies have found emotional reactivity/dysregulation and negative affect, such as anxiety and stress, to be correlated with craving and SUD (2, 5, 29, 30). Excessive stress signaling is thought to prime the brain’s reward system for addictive behaviors (29). Given the role of the reward system in mediating craving and the known negative effects of adverse childhood experiences on emotional regulation, we suspected ACE scores would be associated with increased reports of craving(31). However, no significant relationship was found, contrary to what was hypothesized. There are several possible reasons why this finding may not have been observed. It may indeed be that ACEs are not associated with reported craving, and that the neurobiological and psychological pathways do not align in a way which leads to a direct correlation. Further studies should explore this relationship in order to assess if this finding is replicated. Conversely, certain population that were not represented in our study may demonstrate correlations between ACEs and craving. Our study population included those age 18 and above, but individuals below that age were not included and remain to have unknown clinical correlates of craving. For these individuals in whom childhood traumatic experiences would be recent or even ongoing, and cortical brain networks rapidly developing, craving may be more pronounced. This can similarly be applied to other subpopulations that were not represented in our study. To more comprehensively understand the relationship between ACEs and craving, it may be necessary to examine subpopulations beyond what was explored in this study.
There are several limitations to consider when interpreting the results of this study. Craving is a complex phenomenon that is not always easily and accurately assessed, and thus, the validity of craving measurements has been disputed (11, 32). We utilized a single item question to assess craving and transformed answers into a dichotomous outcome of yes or no. This could have impacted the reliability of the craving measurement and restricted the maximum possible correlation. This study was also limited to those seeking specialty outpatient SUD treatment, and therefore, may not be generalizable to the experience of craving across all those with an SUD, given many never seek treatment or have access to treatment. Lastly, the sample size was not large enough to evaluate the individual effects of substance type (stimulants, opioids, etc.) on craving. We highlighted several areas of research needed to expand on the results found here, including the genetic underpinnings of race and craving, sociocultural factors influencing reports of craving, and the impacts of ACE on craving. These findings may influence how we approach craving as a treatment target.