Integrated cognitive behavioral therapy for cannabis use and anxiety disorders: Rationale and development

Abstract

Cannabis use disorders (CUD) are more common than all other illicit substance use disorders (SUD) combined (Stinson et al., 2006). Quitting cannabis is very difficult (Moore & Budney, 2003) and situations involving negative affect (NA) are among the most difficult situations in which to abstain (Buckner, Zvolensky, & Ecker, 2013). Anxiety is one common type of NA that is systematically and uniquely related to CUD (see Buckner, Heimberg, Ecker, & Vinci, 2013) and greater anxiety at treatment termination predicts greater post-treatment cannabis use and related problems (Buckner & Carroll, 2010). On the other hand, decreases in anxiety during CUD treatment are related to better outcomes (Buckner & Carroll, 2010). The high rates of co-occurring anxiety and SUD and the poorer outcomes among these patients have led to explicit calls for the development of treatments for dually diagnosed patients (National Insitute of Drug Abuse, 2013), including treating anxiety and SUD in an integrated fashion that addresses the reciprocal nature of these disorders (Stewart & Conrod, 2008). False Safety behavior Elimination Treatment (FSET; Schmidt, Buckner, Pusser, Woolaway-Bickel, & Preston, 2012) is a trans-diagnostic anxiety CBT that addresses several anxiety disorders simultaneously by addressing False Safety Behaviors (FSB), or behaviors that help one avoid or alleviate false threats (i.e., phobic stimuli). FSBs are highly utilized across anxiety conditions because they often temporarily alleviate anxiety (e.g., avoiding a phobic stimulus). Yet, repeated use of FSBs can contribute to the maintenance of anxiety disorders (Salkovskis, Clark, & Hackmann, 1991). Thus, FSET involves the identification and elimination of FSBs and has been found to decrease anxiety and depression and improve quality of life (Schmidt et al., 2012). FSET appears particularly well-suited for integration with CUD treatment given that for many anxious individuals cannabis is used to help manage anxiety and related NA (e.g., Buckner, Bonn-Miller, Zvolensky, & Schmidt, 2007; Buckner, Heimberg, Matthews, & Silgado, 2012; Zvolensky et al., 2009). Regardless of whether anxiety or cannabis use begins first, if anxious people use cannabis to manage their NA, they may experience perceived short-term relief, but long-term increases in anxiety related to cannabis use (e.g., anxiety associated with withdrawal), resulting in a positive feedback loop between anxiety and cannabis use. In the absence of adaptive coping strategies, anxious cannabis users may rely on cannabis to manage NA. Yet, continued cannabis use may increase NA via a number of routes, including cannabis withdrawal. Thus, anxious people who use cannabis to cope with NA in the short-term may paradoxically increase their anxiety and cannabis use-related problems in the long-term. The primary aim of the Cannabis REduction and Anxiety Treatment Enhancement (CREATE) project is to compare motivation enhancement therapy (MET) combined with CBT to Anxiety and Cannabis Cessation Treatment (ACCT). ACCT integrates MET-CBT with FSET to simultaneously treat CUD and anxiety disorders. MET-CBT and ACCT will be compared on cannabis use, use-related problems, cannabis use to manage NA, quality of life, and remission of CUD and anxiety disorders. A secondary aim is to identify putative mechanisms (e.g., cannabis use motives, FSB use) by which treatment improves outcomes.