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Marijuana discontinuation, anxiety symptoms, and relapse to marijuana
Addictive Behaviors 34 (2009) 782–785
Contents lists available at ScienceDirect
Addictive Behaviors
Short communication
Marijuana discontinuation, anxiety symptoms, and relapse to marijuana☆ Marcel O. Bonn-Miller ⁎, Rudolf H. Moos Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, United States Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, United States
a r t i c l e Keywords: Marijuana Cocaine Anxiety Treatment Discontinuation Relapse
i n f o
a b s t r a c t The present investigation examined the role of anxiety symptoms immediately following substance abuse treatment in the relation between frequency of pre-treatment marijuana use and relapse to marijuana use at 12-months post-treatment among 1288 male patients who used marijuana within the 3 months prior to admission to treatment. Consistent with expectation, more frequent marijuana use at intake predicted more anxiety symptoms at discharge. Anxiety symptoms at discharge predicted relapse to marijuana use at 12month follow-up, but did not mediate the relation between intake marijuana use and relapse. Results are discussed in relation to better understanding the role of increased anxiety during discontinuation of regular marijuana use in the prediction of relapse to marijuana. Published by Elsevier Ltd.
1. Introduction Recent data suggest that marijuana discontinuation among regular users produces an internally consistent withdrawal pattern, including symptoms such as anxiety and sleep problems (Budney, Moore, Vandrey, & Hughes, 2003; Haney, Ward, Comer, Foltin, & Fischman, 1999). This withdrawal profile tends to appear relatively quickly during the course of addictive use (Budney, Higgins, Radonovich, & Novy, 2000; Copeland, Swift, Roffman, & Stephens, 2001; Stephens, Babor, Kadden, Miller, & the Marijuana Treatment Project Group, 2002) and may predict relapse (Budney, Novy, & Hughes, 1999). The findings suggest that high relapse rates occur after even the best available treatments for marijuana use problems (Budney, Radonovich, Higgins, & Wong, 1998; Stephens, Roffman, & Simpson, 1993). Emerging evidence suggests a link between more frequent, or severe, marijuana use and anxiety symptoms and disorders (BonnMiller, Zvolensky, Leen-Feldner, Feldner, & Yartz, 2005; Brook, Rosen, & Brook, 2001; Degenhardt, Hall, & Lynskey, 2001; Zvolensky et al., 2006, 2008). There is also substantial evidence that individuals with marijuana use disorders (both treatment and non-treatment seeking) have higher rates of psychological symptoms and disorders (including anxiety) relative to individuals without marijuana use disorders ☆ This work was supported by the Department of Veterans Affairs Health Services Research and Development Service funds. We thank Amit Bernstein, Ph.D., John Finney, Ph.D., and Michael J. Zvolensky, Ph.D. for their helpful comments on earlier drafts of the manuscript. The views expressed here are the authors' and do not necessarily represent those of the Department of Veterans Affairs. ⁎ Corresponding author. Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park Division (152), 795 Willow Road, Menlo Park, CA, 94025, United States. Tel.: +1 650 493 5000x27908; fax: +1 650 617 2690. E-mail address: [email protected] (M.O. Bonn-Miller). 0306-4603/$ – see front matter. Published by Elsevier Ltd. doi:10.1016/j.addbeh.2009.04.009
(Agosti, Nunes, & Levin, 2002; Arendt & Munk-Jorgensen, 2004; Rey, Sawyer, Raphael, Patton, & Lynskey, 2002; Troisi, Pasini, Saracco, & Spalletta, 1998; Zvolensky et al., 2006). Accordingly, increasing attention has focused on understanding the contribution of anxiety as a psychological risk factor for marijuana relapse. Although relatively little is known about the association between specific psychological factors and marijuana use disorders, theory points to psychological factors as likely contributors to relapse after temporary cessation of substance use (Moos, 2007). Consistent with this idea, negative psychological symptoms, including anxiety disorders, have been linked to increased relapse risk among current marijuana users (Arendt, Rosenberg, Foldager, Perto, & MunkJorgensen, 2007; Grella, Hser, Joshi, & Rounds-Bryant, 2001; White et al., 2004). As one example, Arendt and colleagues (2007) found that individuals with marijuana dependence and anxiety disorders were at significantly increased risk of later reentry into treatment. The current study aims to extend these findings to a sample of marijuana-using patients in residential treatment for substance use disorders (SUDs). Based on literature showing that marijuana discontinuation results in increases in negative psychological symptoms, especially anxiety (Budney, Hughes, Moore, & Vandrey, 2004; Budney et al., 2003), it was hypothesized that, among patients using marijuana, more frequent marijuana use at intake would predict more anxiety symptoms at discharge, even after controlling for the level of anxiety at intake. It was further hypothesized that anxiety at treatment discharge would predict relapse to marijuana at 12-months post-treatment, and that this association would hold after controlling for the level of anxiety and the frequency of marijuana use at intake. Finally, it was hypothesized that anxiety at treatment discharge would mediate the relation between intake marijuana use and relapse to marijuana at 12-months post-treatment.
M.O. Bonn-Miller, R.H. Moos / Addictive Behaviors 34 (2009) 782–785
2. Method 2.1. Participants A total of 1288 male patients (age M = 39.27 years, S.D. = 7.3) who used marijuana within the 3 months prior to admission to one of 15 Department of Veterans Affairs (VA) residential substance abuse programs were included. Only patients who (1) used marijuana just prior (3 months) to intake, (2) successfully completed treatment, and (3) were abstinent from marijuana during the 2 weeks prior to treatment discharge, were included. The current sample was part of a larger VA-approved treatment evaluation study of male patients with SUDs (Ouimette, Finney, & Moos, 1997). Slightly more than half of the patients were African-America/Black (58.2%), while slightly greater than one-third (37.1%) were White. The remaining patients were Hispanic or Latino (2.5%), Native American (1.4%), Asian (0.1%) and “Other” (0.7%). Trained clinicians evaluated patients for current Axis-I diagnoses. Regarding psychiatric diagnoses at intake, 6.2% of the patients were diagnosed with posttraumatic stress disorder (PTSD), 8.2% with another anxiety disorder, and 8.8% with a depressive disorder. In terms of co-occurring substance use, 23.3% of the sample reported cocaine use, 11.5% reported heroin use, 10.7% reported amphetamine use, 6.5% reported barbiturate use, and 5.4% reported hallucinogen use. More than 94% also used alcohol. 2.2. Measures Anxiety was assessed by six 5-point Likert items drawn from the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983). The items tapped the degree to which participants were distressed or bothered by a variety of problems or symptoms (e.g. “Feeling so restless you couldn't sit still”) in the three months prior to admission and the two weeks prior to discharge. Frequency of substance use was assessed at intake, discharge, and 12-month follow-up with a measure derived from the Treatment Outcome Prospective Study (TOPS; Hubbard et al., 1989). At intake and 12-month follow-up, participants rated their use in the past 3 months, whereas at discharge from treatment, participants rated their use in the past 2 weeks. Patients' substance use at follow-up was verified via biological tests (e.g. urine, blood, breath samples) collected during non-random visits to the VA (e.g. for a medical appointment) prior to or at the 1-year followup. Self-reported abstinence from drugs was significantly associated with negative drug tests (p b .001; Ouimette, Moos, & Finney, 1998). 2.3. Procedure Patients completed the anxiety and substance use measures at admission to treatment and at discharge. At 12-months following discharge, patients again completed the substance use measure. The treatment programs had between a 21 and 28-day length of stay, were staffed with a multidisciplinary team, and employed both individual and group therapy to treat patients. Treatments varied, but generally included 12-step, cognitive-behavioral and combined treatments, though programs did not differ in regard to treatment outcome (Ouimette et al., 1997).
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Table 1 Regression analyses testing for mediation: (1) Effect of intake marijuana use on marijuana relapse at 12-month follow-up, (2) effect of intake marijuana use on discharge anxiety (mediator), after controlling for intake anxiety, (3) effect of discharge anxiety on marijuana relapse at 12-month follow-up after controlling for intake marijuana use and anxiety, and (4) effect of intake marijuana use on marijuana relapse at 12-month follow-up after controlling for intake and discharge anxiety. Exp(B) or Β CI or F
Independent variable(s)
Dependent variable
^1. Intake marijuana use1 #2. Intake anxiety (step 1)4 Intake marijuana use1 ^3. Intake marijuana use (step 1)1 Intake anxiety (step 1)4 Discharge anxiety3 ^4. Discharge anxiety (step 1)3 Intake anxiety (step 1)4 Intake marijuana use1
12-month marijuana relapse2 1.36 Discharge anxiety3 .51 .06 2 12-month marijuana relapse 1.35
1.20–1.55⁎⁎ 458.58⁎⁎ 6.57⁎ 1.19–1.54⁎⁎
1.08 1.46 1.48
.95–1.24 1.20–1.77⁎⁎ 1.23–1.80⁎⁎
.94 1.34
.80–1.10 1.17–1.53⁎⁎
12-month marijuana relapse2
⁎p b .05, ⁎⁎p b .01; ^ = Binary logistic regression; # = Hierarchical multiple regression; Exp(B) = Odds ratio provided for binary logistic regression; β = Standardized beta weight provided for hierarchical multiple regression; CI = Confidence interval provided for binary logistic regression; F = Change in F statistic provided for hierarchical multiple regression; 1 Frequency of Marijuana Use at Intake; 2 Marijuana relapse at 12-Month Follow-Up;3 Discharge Brief Symptom Inventory – Anxiety Subscale;4 Intake Brief Symptom Inventory – Anxiety Subscale.
3.1. Regression analyses Zero-order correlations revealed that intake marijuana use was significantly correlated with both marijuana relapse at 12-month follow-up (r = .15, p b .01) and discharge anxiety (r = .12, p b .01). In addition, discharge anxiety was significantly related to marijuana relapse at 12-month follow-up (r = .14, p b .01). A hierarchical linear regression showed that, after accounting for intake anxiety, intake marijuana use frequency was significantly associated with anxiety symptoms at discharge (β = .06; p = .01; see analysis 2 in Table 1). A binary logistic regression revealed that anxiety at discharge significantly contributed to the prediction of 12-month relapse to marijuana use (coded dichotomously), after accounting for both anxiety and marijuana use frequency at intake (OR = 1.46, 95% CI = 1.20–1.77, p b .01; see analysis 3 in Table 1). A test of meditation (Baron and Kenny, 1986) revealed that discharge anxiety did not mediate the relation between intake marijuana use and 12-month marijuana relapse (see Table 1). Specifically, findings showed no reduction in the relation between intake marijuana use and marijuana relapse with the introduction of discharge anxiety (OR = 1.34 versus 1.35). In order to describe the relation between discharge anxiety and relapse to marijuana, a binary logistic regression was conducted. After accounting for intake anxiety and marijuana use frequency, each unit increase in discharge anxiety resulted in a 1.46 (p b .01, 95% CI = 1.20–1.77) increase in the odds of relapse. Furthermore, when discharge anxiety was split into three groups: no anxiety (mean anxiety BSI = 0), low anxiety (mean anxiety BSI = 0.1–2), and high anxiety (mean anxiety BSI N= 2), patients with high anxiety at discharge showed the highest likelihood of relapse (39.6%) as compared to those with low (29.9%) or no anxiety at discharge (26.9%) (see Fig. 1). 3.2. Subsidiary analyses
3. Results Participants reported using marijuana on average 1–3 times per month during the 3 months prior to admission and slightly more than 30% reported relapse to marijuana use at 12-months following discharge from treatment. On average, participants reported moderate anxiety during the 3 months prior to admission and mild anxiety during the two weeks prior to discharge.
An initial subsidiary analysis revealed no significant differences in 12-month marijuana relapse rates between patients with and without an anxiety disorder diagnosis at intake (Fisher's Exact Test, p = .12, two-tailed), highlighting the importance of examining level of anxiety rather than diagnosis in the current analyses. Another subsidiary analysis was conducted to determine if the primary findings were specific to marijuana or could be applied to other substances as well. A
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measures were utilized as the primary assessment strategy, the results are not fully protected against reporting errors. Third, tobacco use was not assessed in the current sample. Given that recent work has identified tobacco use as important in the context of marijuana use, especially in the prediction of anxiety (Zvolensky et al., 2008), future work should comprehensively assess the use of tobacco. Finally, though the employed anxiety measure is widely used in the literature and in clinical practice, more comprehensive measures of specific anxiety psychopathology (e.g. panic) or vulnerability factors (e.g. anxiety sensitivity; McNally, 2002) might be more useful in future research. References
Fig. 1. 12-month relapse rates among patients with no (M = 0), low (M = 0.1–2), or high (M N= 2) anxiety symptoms at discharge from treatment.
separate subsample (N = 107) of individuals who reported (1) snorting or sniffing cocaine within the 3 months prior to treatment, (2) no marijuana use prior to treatment intake, and (3) abstinence from cocaine during the 2 weeks prior to discharge, was examined. Results indicated a non-significant relation between intake cocaine use and discharge anxiety, after controlling for baseline anxiety (β = .02; p N .10). Additionally, discharge anxiety was not significantly predictive of relapse to cocaine at 12-months, above and beyond the covariates of cocaine use and anxiety at intake (OR = 1.28, 95% CI = 0.62–2.66, p N .10). 4. Discussion Consistent with prediction, after accounting for intake anxiety, frequency of marijuana use at intake predicted anxiety at treatment discharge. Furthermore, consistent with prediction and after accounting for both anxiety symptoms and frequency of marijuana use at intake, anxiety symptoms at treatment discharge predicted 12-month relapse to marijuana use. This pattern of findings is broadly consistent with the literature pointing to increases in anxiety after marijuana discontinuation (Budney et al., 2003, 2004; Haney et al., 1999), as well as theoretical models identifying psychological factors as likely contributors to substance use relapse (Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Hughes, 1993; Hughes & Brandon, 2003; Moos, 2007; Shiffman, 1993; Zvolensky & Bernstein, 2005). Findings also indicated that the relation between intake marijuana use and 12-month marijuana relapse was not mediated by anxiety symptoms at discharge, suggesting that marijuana use frequency and discharge anxiety are distinct predictive factors of marijuana relapse. It is possible, however, that specific anxiety symptoms that are particularly relevant to marijuana use (e.g. panic; Hathaway, 2003; Zvolensky et al., 2006, 2008) might identify a mediational pathway. An identical test among cocaine users revealed non-significant findings, suggesting that the relations observed in the primary analyses may be somewhat specific to marijuana use. Though debate remains about the role of anxiety in the context of cocaine discontinuation/withdrawal, studies have shown that it is a symptom reported by almost half of those who discontinue cocaine use (Coffey, Dansky, Carrigan, & Brady, 2000; Cottler, Shillington, Compton, Mager, & Spitznagel, 1993). As such, it remains puzzling why no relations were found between cocaine use as well as relapse to use, and discharge anxiety. A number of study limitations qualify the present findings. First, the homogeneity of the sample, in terms of gender and veteran status, limits the generalizability of the results. Additionally, as self-report
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Contents lists available at ScienceDirect
Addictive Behaviors
Short communication
Marijuana discontinuation, anxiety symptoms, and relapse to marijuana☆ Marcel O. Bonn-Miller ⁎, Rudolf H. Moos Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, United States Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, United States
a r t i c l e Keywords: Marijuana Cocaine Anxiety Treatment Discontinuation Relapse
i n f o
a b s t r a c t The present investigation examined the role of anxiety symptoms immediately following substance abuse treatment in the relation between frequency of pre-treatment marijuana use and relapse to marijuana use at 12-months post-treatment among 1288 male patients who used marijuana within the 3 months prior to admission to treatment. Consistent with expectation, more frequent marijuana use at intake predicted more anxiety symptoms at discharge. Anxiety symptoms at discharge predicted relapse to marijuana use at 12month follow-up, but did not mediate the relation between intake marijuana use and relapse. Results are discussed in relation to better understanding the role of increased anxiety during discontinuation of regular marijuana use in the prediction of relapse to marijuana. Published by Elsevier Ltd.
1. Introduction Recent data suggest that marijuana discontinuation among regular users produces an internally consistent withdrawal pattern, including symptoms such as anxiety and sleep problems (Budney, Moore, Vandrey, & Hughes, 2003; Haney, Ward, Comer, Foltin, & Fischman, 1999). This withdrawal profile tends to appear relatively quickly during the course of addictive use (Budney, Higgins, Radonovich, & Novy, 2000; Copeland, Swift, Roffman, & Stephens, 2001; Stephens, Babor, Kadden, Miller, & the Marijuana Treatment Project Group, 2002) and may predict relapse (Budney, Novy, & Hughes, 1999). The findings suggest that high relapse rates occur after even the best available treatments for marijuana use problems (Budney, Radonovich, Higgins, & Wong, 1998; Stephens, Roffman, & Simpson, 1993). Emerging evidence suggests a link between more frequent, or severe, marijuana use and anxiety symptoms and disorders (BonnMiller, Zvolensky, Leen-Feldner, Feldner, & Yartz, 2005; Brook, Rosen, & Brook, 2001; Degenhardt, Hall, & Lynskey, 2001; Zvolensky et al., 2006, 2008). There is also substantial evidence that individuals with marijuana use disorders (both treatment and non-treatment seeking) have higher rates of psychological symptoms and disorders (including anxiety) relative to individuals without marijuana use disorders ☆ This work was supported by the Department of Veterans Affairs Health Services Research and Development Service funds. We thank Amit Bernstein, Ph.D., John Finney, Ph.D., and Michael J. Zvolensky, Ph.D. for their helpful comments on earlier drafts of the manuscript. The views expressed here are the authors' and do not necessarily represent those of the Department of Veterans Affairs. ⁎ Corresponding author. Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park Division (152), 795 Willow Road, Menlo Park, CA, 94025, United States. Tel.: +1 650 493 5000x27908; fax: +1 650 617 2690. E-mail address: [email protected] (M.O. Bonn-Miller). 0306-4603/$ – see front matter. Published by Elsevier Ltd. doi:10.1016/j.addbeh.2009.04.009
(Agosti, Nunes, & Levin, 2002; Arendt & Munk-Jorgensen, 2004; Rey, Sawyer, Raphael, Patton, & Lynskey, 2002; Troisi, Pasini, Saracco, & Spalletta, 1998; Zvolensky et al., 2006). Accordingly, increasing attention has focused on understanding the contribution of anxiety as a psychological risk factor for marijuana relapse. Although relatively little is known about the association between specific psychological factors and marijuana use disorders, theory points to psychological factors as likely contributors to relapse after temporary cessation of substance use (Moos, 2007). Consistent with this idea, negative psychological symptoms, including anxiety disorders, have been linked to increased relapse risk among current marijuana users (Arendt, Rosenberg, Foldager, Perto, & MunkJorgensen, 2007; Grella, Hser, Joshi, & Rounds-Bryant, 2001; White et al., 2004). As one example, Arendt and colleagues (2007) found that individuals with marijuana dependence and anxiety disorders were at significantly increased risk of later reentry into treatment. The current study aims to extend these findings to a sample of marijuana-using patients in residential treatment for substance use disorders (SUDs). Based on literature showing that marijuana discontinuation results in increases in negative psychological symptoms, especially anxiety (Budney, Hughes, Moore, & Vandrey, 2004; Budney et al., 2003), it was hypothesized that, among patients using marijuana, more frequent marijuana use at intake would predict more anxiety symptoms at discharge, even after controlling for the level of anxiety at intake. It was further hypothesized that anxiety at treatment discharge would predict relapse to marijuana at 12-months post-treatment, and that this association would hold after controlling for the level of anxiety and the frequency of marijuana use at intake. Finally, it was hypothesized that anxiety at treatment discharge would mediate the relation between intake marijuana use and relapse to marijuana at 12-months post-treatment.
M.O. Bonn-Miller, R.H. Moos / Addictive Behaviors 34 (2009) 782–785
2. Method 2.1. Participants A total of 1288 male patients (age M = 39.27 years, S.D. = 7.3) who used marijuana within the 3 months prior to admission to one of 15 Department of Veterans Affairs (VA) residential substance abuse programs were included. Only patients who (1) used marijuana just prior (3 months) to intake, (2) successfully completed treatment, and (3) were abstinent from marijuana during the 2 weeks prior to treatment discharge, were included. The current sample was part of a larger VA-approved treatment evaluation study of male patients with SUDs (Ouimette, Finney, & Moos, 1997). Slightly more than half of the patients were African-America/Black (58.2%), while slightly greater than one-third (37.1%) were White. The remaining patients were Hispanic or Latino (2.5%), Native American (1.4%), Asian (0.1%) and “Other” (0.7%). Trained clinicians evaluated patients for current Axis-I diagnoses. Regarding psychiatric diagnoses at intake, 6.2% of the patients were diagnosed with posttraumatic stress disorder (PTSD), 8.2% with another anxiety disorder, and 8.8% with a depressive disorder. In terms of co-occurring substance use, 23.3% of the sample reported cocaine use, 11.5% reported heroin use, 10.7% reported amphetamine use, 6.5% reported barbiturate use, and 5.4% reported hallucinogen use. More than 94% also used alcohol. 2.2. Measures Anxiety was assessed by six 5-point Likert items drawn from the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983). The items tapped the degree to which participants were distressed or bothered by a variety of problems or symptoms (e.g. “Feeling so restless you couldn't sit still”) in the three months prior to admission and the two weeks prior to discharge. Frequency of substance use was assessed at intake, discharge, and 12-month follow-up with a measure derived from the Treatment Outcome Prospective Study (TOPS; Hubbard et al., 1989). At intake and 12-month follow-up, participants rated their use in the past 3 months, whereas at discharge from treatment, participants rated their use in the past 2 weeks. Patients' substance use at follow-up was verified via biological tests (e.g. urine, blood, breath samples) collected during non-random visits to the VA (e.g. for a medical appointment) prior to or at the 1-year followup. Self-reported abstinence from drugs was significantly associated with negative drug tests (p b .001; Ouimette, Moos, & Finney, 1998). 2.3. Procedure Patients completed the anxiety and substance use measures at admission to treatment and at discharge. At 12-months following discharge, patients again completed the substance use measure. The treatment programs had between a 21 and 28-day length of stay, were staffed with a multidisciplinary team, and employed both individual and group therapy to treat patients. Treatments varied, but generally included 12-step, cognitive-behavioral and combined treatments, though programs did not differ in regard to treatment outcome (Ouimette et al., 1997).
783
Table 1 Regression analyses testing for mediation: (1) Effect of intake marijuana use on marijuana relapse at 12-month follow-up, (2) effect of intake marijuana use on discharge anxiety (mediator), after controlling for intake anxiety, (3) effect of discharge anxiety on marijuana relapse at 12-month follow-up after controlling for intake marijuana use and anxiety, and (4) effect of intake marijuana use on marijuana relapse at 12-month follow-up after controlling for intake and discharge anxiety. Exp(B) or Β CI or F
Independent variable(s)
Dependent variable
^1. Intake marijuana use1 #2. Intake anxiety (step 1)4 Intake marijuana use1 ^3. Intake marijuana use (step 1)1 Intake anxiety (step 1)4 Discharge anxiety3 ^4. Discharge anxiety (step 1)3 Intake anxiety (step 1)4 Intake marijuana use1
12-month marijuana relapse2 1.36 Discharge anxiety3 .51 .06 2 12-month marijuana relapse 1.35
1.20–1.55⁎⁎ 458.58⁎⁎ 6.57⁎ 1.19–1.54⁎⁎
1.08 1.46 1.48
.95–1.24 1.20–1.77⁎⁎ 1.23–1.80⁎⁎
.94 1.34
.80–1.10 1.17–1.53⁎⁎
12-month marijuana relapse2
⁎p b .05, ⁎⁎p b .01; ^ = Binary logistic regression; # = Hierarchical multiple regression; Exp(B) = Odds ratio provided for binary logistic regression; β = Standardized beta weight provided for hierarchical multiple regression; CI = Confidence interval provided for binary logistic regression; F = Change in F statistic provided for hierarchical multiple regression; 1 Frequency of Marijuana Use at Intake; 2 Marijuana relapse at 12-Month Follow-Up;3 Discharge Brief Symptom Inventory – Anxiety Subscale;4 Intake Brief Symptom Inventory – Anxiety Subscale.
3.1. Regression analyses Zero-order correlations revealed that intake marijuana use was significantly correlated with both marijuana relapse at 12-month follow-up (r = .15, p b .01) and discharge anxiety (r = .12, p b .01). In addition, discharge anxiety was significantly related to marijuana relapse at 12-month follow-up (r = .14, p b .01). A hierarchical linear regression showed that, after accounting for intake anxiety, intake marijuana use frequency was significantly associated with anxiety symptoms at discharge (β = .06; p = .01; see analysis 2 in Table 1). A binary logistic regression revealed that anxiety at discharge significantly contributed to the prediction of 12-month relapse to marijuana use (coded dichotomously), after accounting for both anxiety and marijuana use frequency at intake (OR = 1.46, 95% CI = 1.20–1.77, p b .01; see analysis 3 in Table 1). A test of meditation (Baron and Kenny, 1986) revealed that discharge anxiety did not mediate the relation between intake marijuana use and 12-month marijuana relapse (see Table 1). Specifically, findings showed no reduction in the relation between intake marijuana use and marijuana relapse with the introduction of discharge anxiety (OR = 1.34 versus 1.35). In order to describe the relation between discharge anxiety and relapse to marijuana, a binary logistic regression was conducted. After accounting for intake anxiety and marijuana use frequency, each unit increase in discharge anxiety resulted in a 1.46 (p b .01, 95% CI = 1.20–1.77) increase in the odds of relapse. Furthermore, when discharge anxiety was split into three groups: no anxiety (mean anxiety BSI = 0), low anxiety (mean anxiety BSI = 0.1–2), and high anxiety (mean anxiety BSI N= 2), patients with high anxiety at discharge showed the highest likelihood of relapse (39.6%) as compared to those with low (29.9%) or no anxiety at discharge (26.9%) (see Fig. 1). 3.2. Subsidiary analyses
3. Results Participants reported using marijuana on average 1–3 times per month during the 3 months prior to admission and slightly more than 30% reported relapse to marijuana use at 12-months following discharge from treatment. On average, participants reported moderate anxiety during the 3 months prior to admission and mild anxiety during the two weeks prior to discharge.
An initial subsidiary analysis revealed no significant differences in 12-month marijuana relapse rates between patients with and without an anxiety disorder diagnosis at intake (Fisher's Exact Test, p = .12, two-tailed), highlighting the importance of examining level of anxiety rather than diagnosis in the current analyses. Another subsidiary analysis was conducted to determine if the primary findings were specific to marijuana or could be applied to other substances as well. A
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measures were utilized as the primary assessment strategy, the results are not fully protected against reporting errors. Third, tobacco use was not assessed in the current sample. Given that recent work has identified tobacco use as important in the context of marijuana use, especially in the prediction of anxiety (Zvolensky et al., 2008), future work should comprehensively assess the use of tobacco. Finally, though the employed anxiety measure is widely used in the literature and in clinical practice, more comprehensive measures of specific anxiety psychopathology (e.g. panic) or vulnerability factors (e.g. anxiety sensitivity; McNally, 2002) might be more useful in future research. References
Fig. 1. 12-month relapse rates among patients with no (M = 0), low (M = 0.1–2), or high (M N= 2) anxiety symptoms at discharge from treatment.
separate subsample (N = 107) of individuals who reported (1) snorting or sniffing cocaine within the 3 months prior to treatment, (2) no marijuana use prior to treatment intake, and (3) abstinence from cocaine during the 2 weeks prior to discharge, was examined. Results indicated a non-significant relation between intake cocaine use and discharge anxiety, after controlling for baseline anxiety (β = .02; p N .10). Additionally, discharge anxiety was not significantly predictive of relapse to cocaine at 12-months, above and beyond the covariates of cocaine use and anxiety at intake (OR = 1.28, 95% CI = 0.62–2.66, p N .10). 4. Discussion Consistent with prediction, after accounting for intake anxiety, frequency of marijuana use at intake predicted anxiety at treatment discharge. Furthermore, consistent with prediction and after accounting for both anxiety symptoms and frequency of marijuana use at intake, anxiety symptoms at treatment discharge predicted 12-month relapse to marijuana use. This pattern of findings is broadly consistent with the literature pointing to increases in anxiety after marijuana discontinuation (Budney et al., 2003, 2004; Haney et al., 1999), as well as theoretical models identifying psychological factors as likely contributors to substance use relapse (Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Hughes, 1993; Hughes & Brandon, 2003; Moos, 2007; Shiffman, 1993; Zvolensky & Bernstein, 2005). Findings also indicated that the relation between intake marijuana use and 12-month marijuana relapse was not mediated by anxiety symptoms at discharge, suggesting that marijuana use frequency and discharge anxiety are distinct predictive factors of marijuana relapse. It is possible, however, that specific anxiety symptoms that are particularly relevant to marijuana use (e.g. panic; Hathaway, 2003; Zvolensky et al., 2006, 2008) might identify a mediational pathway. An identical test among cocaine users revealed non-significant findings, suggesting that the relations observed in the primary analyses may be somewhat specific to marijuana use. Though debate remains about the role of anxiety in the context of cocaine discontinuation/withdrawal, studies have shown that it is a symptom reported by almost half of those who discontinue cocaine use (Coffey, Dansky, Carrigan, & Brady, 2000; Cottler, Shillington, Compton, Mager, & Spitznagel, 1993). As such, it remains puzzling why no relations were found between cocaine use as well as relapse to use, and discharge anxiety. A number of study limitations qualify the present findings. First, the homogeneity of the sample, in terms of gender and veteran status, limits the generalizability of the results. Additionally, as self-report
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