The popularity of new slang terms in our study may signal a different population and a reemergence of a black market for cocaine as a rebranding of street terminology is being used to disguise discussion of this illegal drug. Finally, our argument about epidemiological ties with cocaine mentions in song lyrics is strengthened by our results that showed that popular music lyrics related to codeine and heroin did not follow the same trends with cocaine mortality. If this trend in cocaine lyrics continues, we estimate that future incidence of cocaine use may increase by close to 40% and mortality by cocaine use will increase by almost 80% for 2020, making it important to monitor this growth in lyrics about cocaine over time. An important limitation with our study is that our results depict associations and cannot confirm causality. Analytical steps were included in the methodology to remove potential spurious correlations but this is not enough to deem our results as causal. Therefore, our findings should be interpreted with caution. Cocaine street price was included in the model to control for economic fluctuations that would impact purchasing behaviors and initiation of drug use.Further tests on the differenced series confirmed auto correlations were no longer present after first-order differentiation. Another limitation of our study is the potential of not having captured all the cocaine slang terminology to identify song lyrics describing cocaine. Although we queried a number of top websites for the most referenced slang terms for cocaine, it is possible that certain ambiguous slang terms were excluded.

Generating a comprehensive list of slang drug terminology is exceedingly difficult because the vocabulary around cocaine evolves to conceal its discussion. However, indoor plant table sensitivity analyses revealed that our results were robust to the removal of ambiguous terms such as “8-ball”. Inclusion of additional terms like “blow”, which was not included in the model because of its possible description of guns rather than drugs, increased the degree of association between mentions in lyrics and cocaine mortality. Because of this, we believe that genuinely uncertain references to cocaine are rare and have limited potential to significantly alter study results. In this study, we were only able to conduct analyses at the yearly level and not more granularly. Data derived from Lyrics.com is only available at the annual level. We explored several song lyrics engines including Spotify, Genius Lyrics, Metro lyrics, and Billboard; however, these other platforms either do not allow their data to be available or it is also at the yearly level. We selected Lyrics.com because of its word query capabilities within lyrics that other song lyric engines do not provide. This restricted us to have 18 effective observations from 2000 to 2017 for song lyrics data. However, in our analysis, another limiting factor was the incidence of cocaine data from the National Survey on Drug Use and Health published by the Substance Abuse and Mental Health Services Administration and cocaine-related deaths were obtained from the Center for Disease Control Multiple Causes of Death WONDER database, which only are available aggregated at the yearly level. Therefore, our analysis still would have been limited to this level of granularity. Additionally, since our definition of cocaine-related mortality includes deaths using the ICD-10 code T40.5, it may include underlying causes of death other than cocaine.

However, other ICD-10 codes in the mortality dataset do not specify the actual drug involved. While this is a limitation in the use of death certificates for identifying cause-of-death, this is a consistently used measure for cocaine-related deaths. Furthermore, the quality of testing for drug overdose has improved over time. Thus the rise in deaths by cocaine may be in part due to the more accurate determination of deaths attributed to cocaine. Lastly, it is possible that mortality by cocaine could occur in the same year of initiation, which was not seen in our results. However, addiction to cocaine is often characterized by repeated use that changes brain and psychological function that promote transitions to problematic patterns of use. Thus, the accumulation of conditional use of cocaine overtime that leads to mortality by cocaine is likely to occur after years of addictive use of cocaine. In conclusion, these associations underscore the importance of monitoring trends in music to understand drug patterns over time. Media are a powerful indicator of social norms and our study offers initial epidemiological evidence that music lyrics about cocaine may provide an early signal to incidence of cocaine use and mortality. Additionally, new slang terminology for drugs in music lyrics could indicate a new generation of cocaine users and a surge in under-detected use. Future studies should conduct a deeper investigation into lyrics about cocaine and other substances, with particular focus on how these messages may shape cultural perceptions and behaviors toward drug use. Given the wide audience of popular music, popular music artists should consider the potential influence of their lyrics on the drug epidemic impacting today’s youth.Craving for substances is considered essential for understanding the pathogenesis and maintenance of addiction, as highlighted by the incentive salience model and for the inclusion of craving as a criterion for substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases.

Nicotine craving specifically has been shown to predict lapse to cigarette smoking following cessation and is frequently identified by individuals as an important barrier to quitting and maintaining abstinence. Thus, craving represents a clinically important phenotype of nicotine addiction with great potential for intervention. Accurate assessment of craving is essential for the identification, management, and treatment of nicotine and tobacco product use and the use of other substances. In human laboratory studies, craving for nicotine and other abused substances is commonly measured using the cue-exposure paradigm. The translational value of the cue-exposure paradigm to the naturalistic environment is predicated on the observation that relapse to drug use is often precipitated by exposure to drug-related cues that provoke craving. However, naturalistic cues can be very complex and involve a number of contextual factors that are difficult to replicate in laboratory-based cue-exposure paradigms, limiting their ability to invoke a true craving state. New technologies such as virtual reality afford the opportunity to increase the ecological validity of cue-exposure paradigms through the implementation of interactive and immersive presentations of cues within the typical context of use , greatly enhancing our ability to invoke craving in the laboratory. Studies using VR cue-exposure have found great support for its effectiveness in inducing subjective, and in some cases objective, craving for tobacco, as well as alcohol, cannabis, and methamphetamine . Furthermore, despite decades of research, the field of addiction has yet to establish reliable, objective measures of craving. A number of objective correlates of craving have been investigated, including psychophysiological and neurological measures with varying success. Attentional bias, or the ability of drug cues to capture the attention of the user,hydroponic vertical farming can be conceptualized as a behavioral marker of incentive salience and represents an objectively measurable and clinically important phenomenon for the study of addiction. Attentional bias toward smoking cues has been previously demonstrated among regular tobacco smokers, and importantly, it has been related to the risk of subsequent relapse following smoking cessation. Multiple theoretical models suggest that cue-induced subjective craving and attentional bias reflect closely linked underlying processes. Not surprisingly, measures of attentional bias have been shown to correlate with subjective craving. However, the method of assessment appears to be key—direct measures of attention such as the assessment of eye movement, exhibit larger craving correlations and greater reliability than indirect measures such as reaction time. Assessment within naturalistic settings has also independently improved the reliability and validity of attentional bias measurement; yet, the naturalistic constraints of these methods prohibit advanced clinical application of these paradigms. New technological advances in VR implementation allow for the assessment of eye movement in a noninvasive and cost-effective manner and demonstrate early success in distinguishing smokers and nonsmokers on the basis of eye fixations to smoking cues in a virtual world. Spontaneous eye blink rate represents another, much less studied, potential objective correlate of cue-induced craving. EBR has been closely linked with striatal dopaminergic function and has been advanced as a reliable, more cost-effective, and minimally invasive alternative to positron emission tomography to assess dopaminergic functioning. Dopamine release in the basal ganglia inhibits the spinal trigeminal complex, leading to increased EBRs, as demonstrated in both rat and human trials. In line with this theory, preclinical research has shown that direct dopaminergic agonists and antagonists increase and decrease EBRs, respectively. Furthermore, a PET study in monkeys found a strong positive correlation between EBRs and dopamine or D2 -like receptor availability in the striatum.

Given the observed modulation of striatal dopamine during cue-elicited substance craving, it may be possible to detect NTP cue-induced dopamine changes through EBR measurement. Nonetheless, no studies to date have investigated this hypothesis. Lastly, pupillometry represents an additional potential objective craving correlate. Pupil dilation is an indirect measure of norepinephrine release from the locus coeruleus and is associated with reward processing, including sensitivity to rewards, and engagement of cognitive resources. Pupillary responses also seem to index changes in the allocation of attention and have been advanced as an ideal measure for related constructs that may not pass the threshold for overt behavior or conscious appraisal. To our knowledge, only one study has investigated pupillometry as a measure of response to substance cue-exposure. Kvamme et al found that pupillary bias toward alcohol versus neutral cues, but not subjective craving reports, predicted relapse to alcohol use in a sample of detoxified patients with alcohol dependence, suggesting that cue-induced changes in pupillometry may ultimately serve as a useful biomarker for addiction research and clinical care. This study was intended to outline the methods underlying the development of a novel VR-NTP cue-exposure paradigm with embedded eye-characteristic assessments. Preliminary analyses on a pilot sample of participants are also provided as a proof of concept for the potential utility of this paradigm for the induction of subjective craving in the laboratory, assessment of potential biomarkers of craving , and prediction of NTP use behaviors. The NTP Cue VR paradigm uses a virtual reality environment built using Unity. The HTC Vive Pro Eye VR headset was used to enable VR capabilities and collect eye-related data. HTC’s SRanipal SDK was used in conjunction with Tobii’s Tobii XR SDK to provide access to various data from the eye tracker. Specifically, Tobii XR SDK handled object selections, determining what participants were looking at, with its Gaze-to-Object Mapping algorithm, while the rest of the data were retrieved from the SRanipal SDK. The participants were free to move around and interact with various objects within the VR environment using 2 hand-held Vive controllers. Surveys assessing depressed mood and anxiety were presented at the start of the paradigm and additional surveys assessing subjective craving and scene relevance were presented between scenes within the headset. A VAS survey was chosen as the in-task measurement of subjective craving owing to its high face-validity, ability to capture the dynamic fluctuations in craving, and low burden on participants, especially over frequently repeated assessment. Survey responses were made by adjusting a slide bar using one of the controllers. Participants were instructed to “Just explore everything around you until the scene changes” and “During the task, we will be measuring what you pay attention to, and we will be asking you to rate your craving level between each scene.” Three Active scenes and three Neutral scenes were developed and included in the final paradigm . The Active scenes include NTP-related cues, while in the Neutral scenes, all cues are neutral. Active cues include ashtrays, lighters, JUUL devices, cigarettes , Puffbars, hookahs, as well as the presence of human models engaged in smoking or vaping behaviors. Neutral cues vary depending on the scene context. All cues are interactable such that the participants are able to pick up, throw, and collide the items with other items in the scene. All scenes include the presence of at least one animated human model. Smoke and vapor effects are incorporated with the animated human models in the Active scenes to increase the immersiveness of the experience.