From intrusive memory to craving in cocaine use disorder – An ecological momentary assessment study

Background: Cocaine globally involves around 21 million users, with a potential one-fifth facing the risk of developing a cocaine use disorder (CUD). Previous studies have emphasized the role of craving as a significant contributor to CUD and relapse. However, the factors driving craving, particularly preceding cognitive events such as intrusive substance-related memories in those with CUD, remain insufficiently explored. Our study thus aims to elucidate the dissociability of intrusive cocaine-related memories from craving in individuals with CUD and, in a second step, to identify specific associations between intrusion characteristics and craving.
Methods: Experienced intrusive memories as well as the occurrence and severity of cocaine craving were assessed by means of a smartphone-based Ecological Momentary Assessment (EMA) in 43 participants with CUD and over the course of 14 days. Linear probability models and linear fixed effect models were used to investigate potential associations between intrusive memory characteristics and craving likelihood or severity, respectively.
Results: Cocaine users exhibited discriminative abilities in distinguishing intrusive episodes with or without concurrent or subsequent craving symptoms. Notably, variability in these episodes was evident both inter- and intra-individually. Various features of intrusive memories, such as experienced intrusiveness, distress, and loss of control, positively correlated with craving likelihood and severity. Likewise, intrusions triggered by environmental cues and those manifested as bodily sensations were associated with increased craving frequency and severity. Additionally, emotional responses like anger, guilt, yet also joyful anticipation significantly related to heightened craving. Finally, the subsequent pursuit of cocaine was plausibly linked to intensified craving. 
Conclusions: This study not only provides evidence supporting the distinction between intrusive memories and craving but also identifies specific facets of intrusive memories that influence craving most strongly. We propose that the separation of these concepts and recognizing intrusive substance-related memories as possible precursors of craving and substance use may be crucial for improving the psychotherapeutic treatment of CUD.