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					Alcohol & Drug Abuse

A Preliminary Investigation of
Cocaine Craving Among Persons
With and Without Schizophrenia
Genata Carol, Ph.D.
David A. Smelson, Psy.D.
Miklos F. Losonczy, M.D., Ph.D.
Douglas Ziedonis, M.D., M.P.H.

C    ocaine abuse and dependence
     are common among persons who
have schizophrenia, and prevalence
                                              ance, violence, HIV infection and
                                              other medical problems, housing in-
                                              stability, homelessness, and higher
                                                                                         this population have used craving as a
                                                                                         secondary outcome measure. Our
                                                                                         clinical experience indicates that
rates vary by setting. Studies have es-       health care costs (3,4). In general,       among cocaine-dependent persons,
timated that 16 to 40 percent of per-         when a person who has schizophrenia        those who have schizophrenia com-
sons who have schizophrenia abuse             is abusing cocaine, treatment is more      plain more about high-intensity and
cocaine, and rates are as high as 70          challenging. However, some patients        persistent cocaine craving than those
percent in some hospital emergency            respond well to addiction treatment        who do not have schizophrenia. There-
services, inpatient units, and outreach       that involves focused interventions.       fore, we undertook this study to eval-
programs (1,2).                               Others require extensive treatment         uate whether individuals who have
  The high rates are of particular            that integrates addiction and mental       schizophrenia and cocaine depend-
concern because cocaine use by per-           health treatment.                          ence experience more intense craving
sons who have schizophrenia leads to             A variety of hypotheses have been       than cocaine addicts who do not have
increases in the severity of positive         proposed to explain why persons            schizophrenia. We were also interest-
symptoms, treatment noncompli-                who have schizophrenia abuse co-           ed in using a repeated-measures de-
                                              caine. They include greater dysregu-       sign to examine the stability of crav-
                                              lation in the dopamine system, a de-       ing during the first few days of absti-
Dr. Carol is affiliated with the Gordon F.    sire to reduce negative symptoms or        nence from cocaine.
Derner Institute of Advanced Psychologi-      the unwanted side effects of conven-
cal Studies at Adelphi University in Gar-     tional neuroleptic medications, lim-       Methods
den City, New York. Dr. Carol, Dr.            ited social and community support,         We compared cocaine craving in two
Smelson, and Dr. Losonczy are with the        and social isolation (5). In addition,     groups: 20 cocaine-dependent male
Veterans Integrated Service Network 3
                                              deinstitutionalization has resulted in     outpatients who had schizophrenia
Mental Illness Research, Education, and
                                              increased substance use because of         and who were participating in a
Clinical Center at the Veterans Affairs
New Jersey Health Care System. Dr.            easier access to drugs (5).                chemical abuse program for persons
Smelson, Dr. Losonczy, and Dr. Ziedo-            Neuroimaging studies suggest that       with mental illness and 20 cocaine-
nis are with the University of Medicine       aberrations in the dopamine system         dependent men who did not have
and Dentistry of New Jersey–Robert            play a role both in schizophrenia and      schizophrenia and who were recruit-
Wood Johnson Medical School. Send cor-        in maintaining cocaine addiction via       ed from the substance abuse outpa-
respondence to Dr. Smelson at the De-         craving. Craving is a manifestation of     tient treatment program at the Veter-
partment of Veterans Affairs, New Jersey      internal affective and motivational        ans Affairs New Jersey Health Care
Health Care System, Lyons Campus,             processes that can persist for three to    System. The study was conducted in
Mental Health and Behavioral Sciences         12 months after last use, although the     1998 and 1999.
Building 143, 151 Knollcroft Road, Lyons,
                                              intensity of craving is highest during        To be included in the study, partic-
New Jersey 07939-5000 (e-mail, david.
                                              the first three months of abstinence       ipants had to meet DSM-IV criteria Parts of this col-
umn were presented at the annual meet-        or in response to specific triggers (6).   for cocaine dependence, to report
ing of the American Psychiatric Associa-         Few studies have directly examined      having used at least six grams of co-
tion held May 13–18, 2000, in Chicago.        craving in individuals who have co-        caine a month, and to have been ab-
Richard J. Frances, M.D., is editor of        caine dependence and schizophrenia,        stinent from cocaine for two weeks at
this column.                                  although several medication trials in      the time of the study. The patients
PSYCHIATRIC SERVICES   o August 2001 Vol. 52 No. 8                                                                         1029
Table 1                                                                                                         Results
Substance use patterns among persons with cocaine dependence who had schizo-                                    No significant differences were found
phrenia (N=20) and those who did not (N=20)1                                                                    in sociodemographic characteristics
                                                                                                                or in the frequency, intensity, or dura-
                                                          With                       Without                    tion of substance use between co-
                                                          schizophrenia              schizophrenia              caine-dependent persons who had
Variable                                                  Mean           SD          Mean      SD
                                                                                                                schizophrenia and those who did not.
                                                                                                                The mean±SD age of patients in the
Age at first use of cocaine (years)                       25.3            6.4        25.8          8.4          schizophrenia group was 25.3±6.4
Lifetime cocaine use2                                      2.6             .83       26             .83         years. Eighteen (90 percent) of the
Longest period of abstinence from                                                                               patients in this group were African
  cocaine (weeks)                                         50.9           73.52       36.3      46.57
Most recent cocaine use3
                                                                                                                American, one (5 percent) was His-
                                                           2.2             .89        2.5        .61
                                                                                                                panic, and one was white. The mean±
1   No significant differences were found between the two groups.                                               SD age of patients in the group with-
2   Number of times used: 1, 1 to 99; 2, 100 to 199; 3, 200 or more
                                                                                                                out schizophrenia was 25.8±8.4 years.
    1, two weeks ago; 2, two to four weeks ago; 3, four to eight weeks ago
                                                                                                                Fifteen (75 percent) were African
                                                                                                                American, four (20 percent) were
                                                                                                                Hispanic, and one (5 percent) was
met DSM-IV criteria for schizophre-                   analogue scale (7). The VCCQ was                          white. Table 1 summarizes data about
nia. Diagnoses of schizophrenia and                   chosen because of its good reliability                    cocaine use in the two groups. How-
cocaine dependence were made inde-                    and validity when used with cocaine-                      ever, as shown in Table 2, persons in
pendently by a doctoral-level psychol-                dependent persons who do not have                         the schizophrenia group reported a
ogist. Persons were excluded who had                  schizophrenia (7) and because most                        significantly higher level of craving,
a history of dependence on opiates,                   psychiatric patients find it easy to                      depression, and energy and felt worse
barbiturates, benzodiazepines, mari-                  complete. The four items on the scale                     than those in the comparison group.
juana, or alcohol; who met DSM-IV                     include craving intensity, measured                          Craving stability over the 72-hour
criteria for another current axis I dis-              along a scale from craving to no crav-                    period was high in both groups on
order; and who had been abstinent                     ing; mood, happy to sad; energy, too                      three of the four items—depression
from cocaine for more than two                        little to too much; and feeling, good                     (Pearson’s correlation coefficient=
months. Persons were excluded from                    to bad. The intensity item measures a                     .73), energy (.64), and feeling (.68).
the comparison group if they were                     person’s craving state, and the other                     In both groups, the intensity of crav-
currently taking prescribed medica-                   three items measure subcomponents                         ing was slightly less stable (.53).
tion that could affect the central nerv-              of that state. Respondents score each
ous system; patients who had schizo-                  item by marking a line through a 50-                      Discussion
phrenia were not excluded for this                    point scale that reflects their current                   The findings support our hypothesis
reason. Institutional review board ap-                state. To examine craving stability, we                   that during early abstinence, co-
proval was obtained for this study.                   administered the VCCQ at baseline                         caine-dependent persons who have
   After giving written informed con-                 and 72 hours later.                                       schizophrenia experience more in-
sent, participants completed a demo-                     Student’s t test was used to examine                   tense cocaine craving than cocaine-
graphic survey and the Voris Cocaine                  group differences in cocaine craving,                     dependent persons who do not have
Craving Questionnaire (VCCQ), a                       and Pearson’s correlation coefficient                     schizophrenia. We also found that
four-item, self-report, 50-point visual               was used to examine craving stability.                    the intensity of cocaine craving re-

Table 2
Scores on the Voris Cocaine Craving Questionnaire among persons with cocaine dependence who had schizophrenia (N=20)
and those who did not (N=20)1

                      Score at baseline                                                     Score at 72 hours

                      With                   Without                                        With                     Without
                      schizophrenia          schizophrenia                                  schizophrenia            schizophrenia

Item                  Mean        SD         Mean       SD          t†           p          Mean          SD         Mean     SD         t†          p

Craving                10.7       6.0        6.6        4.8         2.36         .02        10.3          6.7        6.7      6.0        1.78        .08
Depression             13.45      7.0        7.8        5.8         2.8          .008       13.0          7.0        7.8      6.4        2.45        .01
Energy                 12.0       4.9        7.7        4.7         2.8          .007       12.1          5.3        7.9      4.4        2.73        .01
Feelings                8.95      6.6        4.7        3.4         2.5          .017        9.1          7.3        3.9      2.9        2.93        .006
1   Possible scores on each item range from 1 to 50, with higher scores indicating higher levels of craving, depression, and energy and worse feelings.
†   df=38

1030                                                                                               PSYCHIATRIC SERVICES     o August 2001 Vol. 52 No. 8
                                                                                                  toms to cocaine abuse in schizophrenia.
mained stable over a 72-hour period           open pilot pharmacotherapy studies                  Journal of Nervous and Mental Disease
in both groups.                               suggest that patients taking the atyp-              182:109–112, 1994
   Cocaine-dependent persons who              ical agents clozapine, olanzapine, and           4. Serper MR, Alpert M, Richardson NA, et al:
have schizophrenia may be particu-            risperidone have better treatment                   Clinical effects of recent cocaine use on pa-
larly vulnerable to relapses and may          outcomes, including treatment for                   tients with acute schizophrenia. American
                                                                                                  Journal of Psychiatry 152:1464–1469, 1995
require specialized psychosocial and          cocaine addiction, than those taking
pharmacological interventions to              conventional neuroleptics (11–13).                5. Drake RE, Wallach MA: Substance abuse
                                                                                                   among the chronically mentally ill. Hospital
manage their craving and to reduce            Psychosocial treatments have also                    and Community Psychiatry 40:1041–1046,
relapses. The persistently high level         been developed that blend and mod-                   1989
of craving noted in this study may            ify the best psychosocial approaches
                                                                                                6. Gawin FH, Kleber HD: Cocaine Use in a
partly account for the poorer reten-          in mental health treatment—social                    Treatment Population: Patterns and Diag-
tion in outpatient treatment and re-          skills training, case management, and                nostic Distinctions. NIDA Research Mono-
current hospitalizations in this popu-        outreach—and the best psychosocial                   graph 61. Rockville, Md, National Institute
                                                                                                   on Drug Abuse, 1985
lation (8). These patients also appear        approaches in addiction treatment—
to be particularly vulnerable to the          relapse prevention, cognitive-behav-              7. Smelson DA, McGee-Caulfield E, Berg-
                                                                                                   stein P, et al: Initial validation of the Voris
instability that frequently accompa-          ioral therapy, motivational enhance-                 Cocaine Craving Scale: a preliminary re-
nies the transition from inpatient to         ment therapy, and 12-step recovery                   port. Journal of Clinical Psychology 55:
outpatient treatment (9). A higher            programs. Clinical experience and                    135–139, 1999
level of cocaine craving may be relat-        research support the integration of               8. Ho AP, Tsuang JW, Liberman RP, et al:
ed to having a neurobiological vul-           mental health and addiction treat-                   Achieving effective treatment of patients
                                                                                                   with chronic psychotic illness and comorbid
nerability and more psychosocial in-          ments, pharmacotherapy, and psy-                     substance dependence. American Journal
stability.                                    chosocial treatments to best treat co-               of Psychiatry 156:1765–1770, 1999
   These preliminary results should           caine addiction (14).                             9. Broadnick PS, Schmitz JM: Cocaine crav-
be interpreted with caution given the            We and others are currently con-                  ing: an evaluation across treatment phases.
small sample and lack of a structured         ducting double-blind studies to inte-                Journal of Substance Abuse 10:9–17, 1997
interview to maximize diagnostic cer-         grate psychosocial and pharmacologi-             10. Smelson DA, Roy M, Roy A, et al: Elec-
tainty. Furthermore, the study relied         cal interventions and to determine                   troretinogram in withdrawn cocaine-de-
                                                                                                   pendent subjects: relationship to cue-elicit-
on a self-reported measure of crav-           whether use of conventional or atypi-                ed craving. British Journal of Psychiatry
ing. Laboratory exposure to drug              cal neuroleptics is associated with less             172:537–539, 1998
cues, such as videotapes of cocaine           intense cocaine craving and fewer re-
                                                                                               11. Smelson DA, Kaune M, Kind J, et al: The
and of people using it, would have            lapses among persons who have schiz-                 efficacy of olanzapine versus haloperidol in
helped determine group differences            ophrenia and cocaine dependence. o                   decreasing cue-elicited craving and relapse
in craving in a controlled setting (10).                                                           in withdrawn cocaine dependent schizo-
                                              Acknowledgment                                       phrenics. Presented at the National Insti-
Such exposure provides an opportu-                                                                 tute on Drug Abuse New Clinical Drug
nity to examine an individual’s trig-         The authors thank Aron Starosta, M.D.,               Evaluation Unit Conference, Rockville,
gers for cocaine use and to monitor           for helpful comments.                                Md, May 1999
the intensity of response.                                                                     12. Buckley P: Novel antipsychotic medications
   Because persons who have schizo-           References                                           and the treatment of comorbid substance
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                                                 morbidity of mental disorders with alcohol
or self-medicate their negative symp-            and other drug abuse. JAMA 264:2511–          13. Yovell Y, Opler LA: Clozapine reverses co-
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fects of medication, future investiga-        2. Ziedonis DM, Trudeau K: Motivation to             tally ill chemical abuser: a case report and a
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                                                 with schizophrenia. Schizophrenia Bulletin        Disease 182:591–592, 1994
toms and side effects as dependent               23:229–238, 1997
variables. It is interesting that pre-                                                         14. Ziedonis DM, Williams J, Corrigan P, et al:
                                              3. Lysaker P, Bell M, Beam-Goulet MS, et al:         Management of substance abuse in schizo-
liminary reports suggest that atypical           Relationship of positive and negative symp-       phrenia. Psychiatric Annals 30:67–75, 2000
neuroleptics, which are thought to
produce fewer extrapyramidal symp-
toms and negative symptoms and to
reduce dopamine transmission dur-
ing acute withdrawal, have been                           Change of Address: Authors, Reviewers
shown to reduce craving among per-
sons who have schizophrenia and co-                       Authors of papers currently being reviewed by Psychiatric
caine dependence (11).                                    Services and peer reviewers for the journal are reminded
   The relationship between cocaine                       to notify the editorial office of any changes in address.
craving and relapse to both drug use                      Please call the editorial office at 202-682-6070, or send
and psychiatric illness supports con-                     updated information by fax to 202-682-6189 or by e-mail
tinued efforts to evaluate medica-                        to
tions and psychosocial treatment ap-
proaches. Several naturalistic and
PSYCHIATRIC SERVICES   o August 2001 Vol. 52 No. 8                                                                                          1031