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A Preliminary Study on Discomfort, Pain, and Chronic Pain with Cannabis

Student's Name

Institutional Af�liation

Instructor

Course

Date

A Preliminary Study on Discomfort, Pain, and Chronic Pain with Cannabis

Introduction

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Cannabis use is more common among people who have long-term pain, and it is

often used to relieve physical pain. On the other hand, not much is known about

the factors that lead people with chronic pain to use cannabis. However, there

is reason to think that feelings of pain may play a role in this connection.

Intolerance, which is also called DI, is a big part of how pain and cannabis work

together. The goal of this study was to get a �rst look at how often people with

chronic pain use cannabis and how that affects how they feel, how bad their

pain is, and how much it gets in the way of their lives. More speci�cally, they

thought that the intensity and interference of pain, as well as the avoidance

and intolerance of DI, would be linked to how often people used cannabis.

Methods

The information was gathered through an online survey. To take part, people

had to be 18 or older, permanent U.S. citizens, �uent English speakers, able to

read and write in English, and willing to give their permission electronically. The

study used multilayer linear regression models to look at the links between

pain intensity or interference and DI, as well as between pain intensity or

interference and DI and the outcome measure of cannabis use. Since getting

old and being gay are constants, they were always included as variables in all

models (Ditre et al., 2015). Given how often people use both cannabis and

tobacco, how well tobacco use and chronic pain go together, and how important

it is to stay consistent with how data has been analyzed in the past, cigarette

use status was added as a covariate. Since there are good reasons to use

cannabis when you have anxiety or depression.

Results

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The results showed that most of the people who took part (N = 109, 44% were

men, and the average age was 27) had chronic pain and had used cannabis at

least once in their lives. Most of the participants (n = 38) said they used

cannabis "less than once a month," while most of the participants (n = 32) said

they used it "daily or almost daily." Most people thought their chronic pain was

very bad but didn't affect them much (Kosiba et al. 2020). According to the

results, pain intensity, pain avoidance, and pain-related problems were all

linked to how often people used cannabis in a positive way. But cannabis use

was not shown to make people less able to handle pain.

Discussion

This study examined the cross-sectional relationships among DI, pain severity

in the last month, pain-related interference, and cannabis usage frequency.

Consistent with predictions, chronic pain patients who reported higher pain

intensity, pain interference, and pain avoidance also reported higher rates of

cannabis usage. As was also anticipated, there was a positive correlation

between pain-related interference and avoidance and intolerance of perceived

discomfort (Kosiba et al., 2020). Positive relationships between discrimination

of pain and how often people use cannabis did not reach statistical

signi�cance. This suggests that factors related to the subfactor of discomfort

avoidance may be more critical to how often people with chronic pain use

cannabis.

Conclusion

These early results imply that ongoing exploration of perceived discomfort

avoidance in connection to co-occurring pain and cannabis usage is necessary.

These �ndings are from a study that was conducted in the United Kingdom.

More research should be done to see if these results hold for people in pain

who are currently being treated with medical cannabis.

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References

Ditre, J. W., Langdon, K. J., Kosiba, J. D., Zale, E. L., & Zvolensky, M. J. (2015).

Relations between pain-related anxiety, tobacco dependence, and barriers to

quitting among a community-based sample of daily smokers. Addictive

Behaviors, 42, 130-135.

Kosiba, J. D., Mitzel, L. D., Zale, E. L., Zvolensky, M. J., & Ditre, J. W. (2020). A

preliminary study of associations between discomfort intolerance, pain

severity/interference, and frequency of cannabis use among individuals with

chronic pain. Addiction research & theory, 28(1), 76-81.

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ORIGINAL ARTICLE

A preliminary study of associations between discomfort intolerance, pain severity/interference, and frequency of cannabis use among individuals with chronic pain

Jesse D. Kosibaa, Luke D. Mitzela, Emily L. Zaleb, Michael J. Zvolenskyc,d,e and Joseph W. Ditrea

aDepartment of Psychology, Syracuse University, Syracuse, NY, USA; bDepartment of Psychology, Binghamton University, Binghamton, NY, USA; cDepartment of Psychology, University of Houston, Houston, TX, USA; dDepartment of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; eHealth Institute University of Houston, Houston, TX, USA

ABSTRACT Background: Cannabis use is more common among individuals with chronic pain, and is often used to relieve physical discomfort. However, little is known about factors that are associated with cannabis use among individuals with chronic pain, and there is reason to suspect that perceptions of discomfort intolerance (DI) play an important role in pain-cannabis relations. Method: The goal of this study was to conduct an initial examination of perceived DI, pain severity, and pain-related interference in relation to frequency of cannabis use among individuals with chronic pain. Specifically, we hypothesized that pain severity/interference and factors of DI (avoidance and intolerance), would each be positively associated with cannabis use frequency. Results: Participants (N¼ 109; 44% male; Mage¼ 27) endorsed chronic pain and at least one instance of lifetime cannabis use. Most participants characterized their chronic pain as high intensity and low disability, and the two most commonly reported frequencies of cannabis use were “less than monthly” (n¼ 38), and “daily/almost daily” (n¼ 32). Results indicated that discomfort avoidance (but not discom- fort intolerance), pain severity, and pain-related interference were each independently and positively associated with frequency of cannabis use. Conclusions: These preliminary findings suggest that continued examination of perceived discomfort avoidance in relation to co-occurring pain and cannabis use is warranted. Future research should repli- cate these results among treatment-seeking pain patients who are prescribed medical cannabis.

ARTICLE HISTORY Received 3 July 2018 Revised 12 February 2019 Accepted 14 February 2019

KEYWORDS cannabis; discomfort intolerance; chronic pain; pain-related interference

Introduction

Up to 100 million adults in the United States suffer from chronic pain, accounting for an estimated $500 billion in annual health care expenses and lost productivity (Institute of Medicine 2011). The prevalence of cannabis use and can- nabis use disorder is on the rise in the United States (UNODC 2017), and cannabis use is more common among individuals with chronic pain, relative to those without chronic pain (Zvolensky et al. 2011; Smiley-McDonald et al. 2017). Pain severity and pain-related functional impairment also tend to be greater among cannabis users (vs. non-users) with chronic pain (Degenhardt et al. 2015), and researchers have recently begun testing associations between affective components of pain and cannabis cessation/withdrawal experiences (Manning et al. 2018).

Recent work has also examined psychological constructs associated with the use of cannabis in chronic pain (Walsh et al. 2013; Hill et al. 2017), including potential transdiag- nostic factors such as perceived discomfort intolerance (DI; Schmidt et al. 2006; Leyro et al. 2010). Perceived DI is thought to be composed of two subfactors, including

discomfort intolerance (i.e., inability to tolerate uncomfort- able physical sensations), and discomfort avoidance (i.e., tendency to reflexively avoid or escape uncomfortable phys- ical sensations; Schmidt et al. 2006; Bonn-Miller et al. 2009). Greater perceived DI has been positively associated with negative-reinforcement substance use motives (Leyro et al. 2008). There is evidence of an inverse relation between per- ceived DI and frequency of cannabis use among college stu- dents (Buckner et al. 2007). Furthermore, several positive associations between perceived DI and somatic symptoms have been observed among adults with chronic abdominal pain (Keough et al. 2011), and obese primary care patients (Fergus et al. 2018). Thus, positive relations between per- ceived DI and cannabis use may be more pronounced among individuals with chronic pain or other med- ical conditions.

Recent clinical trials indicate that pain can be inhibited following the administration of inhaled cannabis (Wilsey et al. 2016; National Academies of Sciences 2017). Medical cannabis patients with chronic pain have reported that can- nabis use “changes perception and experience of chronic pain” and helps them to “tolerate the pain a little better” (Piper

CONTACT Joseph W. Ditre [email protected] Department of Psychology, Syracuse University, Syracuse, NY 13244, USA � 2019 Informa UK Limited, trading as Taylor & Francis Group

ADDICTION RESEARCH & THEORY 2020, VOL. 28, NO. 1, 76–81 https://doi.org/10.1080/16066359.2019.1590557

et al. 2017). In addition, frequent cannabis users readily endorse the utility of cannabis in relieving aversive internal experiences (i.e., depression, nervousness; Buckner 2013; Bonar et al. 2017), and they are more likely to expect that cannabis will also diminish physical discomfort, relative to non-cannabis users (Schafer and Brown 1991). Results of neuroimaging studies further suggest that pain may be easier to tolerate following cannabis self-administration, even in the absence of a direct reduction in pain intensity (Lee et al. 2013).

Despite the emergence of research suggesting that pain, perceived DI, and cannabis use may be interrelated, we are not aware of any previous work that examined covariation between these factors among individuals with chronic pain. Frequent exposure to cannabis may result in tolerance to its pain-reducing effects via downregulation of CB1 cannabin- oid receptors (Cooper and Haney 2008; D’Souza et al. 2016), which in turn may contribute to increased use, higher dos- ing, and the onset of unwanted effects (e.g., increase sensi- tivity to pain; Wallace, 2007). Cannabis use frequency is of particular clinical interest because it is a primary criterion for cannabis use disorder (DSM-5; American Psychiatric Association 2013), and is among the most commonly exam- ined outcomes of cannabis cessation interventions (Gates et al. 2016).

The goal of this study was to conduct an initial test of cross-sectional associations between pain severity, pain- related functional interference, perceived DI, and frequency of cannabis use among a sample of individuals with chronic pain. First, we hypothesized that perceived discomfort intolerance and avoidance would each be independently associated with greater pain severity and pain-related inter- ference. Second, we hypothesized that pain severity/interfer- ence and discomfort avoidance/intolerance would each be independently and positively associated with cannabis use frequency.

Method

Participants

Participants completed an online survey of substance use and health (Ditre et al. 2017), and were required to be at least 18 years of age, United States residents, able to read and write English, and willing to provide electronic informed consent. Survey measures were administered through socialsci.com, a web-based service that connects researchers with adult residents of the United States who agree to participate in IRB-approved research studies in exchange for small points-based rewards. The current study is based on a sub-sample of the 706 survey respondents (n¼ 261) who screened positive for chronic pain using a single item adapted from the Kansas Behavioral Risk Factor Surveillance System (Toblin et al. 2011) and the National Health Interview Survey (National Health and Nutrition Examination Survey Data 2012) that stated: “Do you cur- rently suffer from any type of chronic pain, that is, pain that occurs constantly or flares up frequently? Do not report aches and pain that are fleeting or minor.” Chronic pain status and

severity was further assessed using the Graded Chronic Pain Scale (GCPS; Grade I¼ low intensity–low interference; Grade II¼ high intensity–low interference; Grade III¼ high disability–moderately limiting; and Grade IV¼ high disabil- ity-severely limiting; Von Korff et al. 1992). The current analyses were restricted to the subsample of respondents who also indicated having used cannabis at least once in their lifetime (n¼ 109).

Measures

Sociodemographic Characteristics and Tobacco Use. Sociodemographic and tobacco use characteristics including age, gender, race/ethnicity, education, and income are pre- sented in Table 1. Tobacco use was self-reported and opera- tionalized as “never”, “former”, “current, occasional” or “current, daily”.

Anxiety Symptoms. The Generalized Anxiety Disorder–7 (GAD-7) questionnaire is a 7-item measure of anxiety symp- toms that was developed as a screening tool for anxiety dis- orders (Kroenke et al. 2007). The measure asks participants to rate how much they have been bothered by specific anx- iety symptoms (e.g., Feeling nervous, anxious, or on edge?) over the last 2 weeks on a Likert-type scale from 0 (not at all) to 3 (nearly every day) (Spitzer et al. 2006). The GAD-7 demonstrated excellent consistency in the current sam- ple (a¼ 0.90).

Depression Symptoms. The Center for Epidemiological Studies Depression Scale (CES-D) is a 20-item measure of depressive symptomology (Radloff 1977). The CES-D has evinced good construct validity, very high internal consist- ency, and adequate test-retest reliability in general popula- tion samples (Radloff 1977). The CES-D demonstrated adequate internal consistency in the current sam- ple (a¼ 0.77).

Chronic Pain-Related Interference. The Graded Chronic Pain Scale (GCPS) is a self-report measure that was used to characterize the severity of chronic pain- related functional interference on a linear scale (Von Korff et al. 1992). The scale yields an interference score (Range 0–40) that is calculated by summing items that assess pain-related interference associated with daily/work activities, social activities, and family activities (0¼ no interference; 10¼ unable to carry on any of these activities).

Past-Month Pain Severity. A single item derived from the Short Form Health Survey – 20 (SF-20) was used to assess the severity of past-month pain (i.e., “How much bod- ily pain have you had during the past four weeks”(Stewart and Ware 1992). Response options ranged from 0 (None) to 5 (Severe).

Perceived Discomfort Intolerance (DI). The Discomfort Intolerance Scale (Schmidt et al. 2006) is a 5-item measure that indexes individual differences in the perceived capacity to tolerate uncomfortable somatic sensations. This measure of perceived DI is comprised of two subfactors (i.e., discomfort intolerance and discomfort avoidance) (Schmidt et al. 2006; Bonn-Miller et al. 2009). The discomfort intolerance subscale

ADDICTION RESEARCH & THEORY 77

(3 items) measures inability to tolerate physical discomfort and pain, with higher scores reflecting less tolerance for uncomfortable physical sensations. The discomfort avoidance subscale (2 items) measures tendency to avoid or escape uncomfortable physical sensations, with greater scores reflecting stronger tendency to avoid aversive physical sensa- tions (Schmidt et al. 2006; Bernstein et al. 2009). The Discomfort Intolerance Scale has evidenced good test-retest reliability (Schmidt et al. 2006), and both subscales demon- strated adequate internal consistency in the current sample (discomfort intolerance a ¼ 0.77; discomfort avoid- ance a ¼ 0.73).

Cannabis Use Frequency. Consistent with previous research (Khazaal et al. 2015), participants who endorsed lifetime cannabis use were subsequently asked to indicate their current frequency of use via a Likert-type scale with the following response options: 0 (None), 1 (Less than Monthly), 2 (A few times a month), 3 (A few times a week), and 4 (Daily or almost daily). The distribution of the cannabis use frequency variable was examined for normality, which indicated it was only slightly platykurtic (Kurtosis¼�1.49, SE¼ .46), with no evidence of

skewness (skew¼ .07, SE¼ .23). Thus, no transformation was applied.

Data analytic strategy

Hierarchical linear regression models were used to test rela- tions between pain severity/interference and DI, and to test pain severity/interference and DI in relation to the criterion variable of cannabis use frequency. Age and sex were identi- fied a priori for inclusion as covariates in all models because they are considered non-modifiable risk factors for chronic pain (Bartley and Fillingim 2013; van Hecke et al. 2013). Tobacco use status was included as a covariate given high rates of comorbid cannabis and tobacco use (Schauer et al. 2017), positive associations between tobacco use and chronic pain (Zale et al. 2016), and to be consistent with previous data analytic approaches (Hogan et al. 2010). Anxiety and depression scores were also included as covariates given posi- tive associations with cannabis use (National Academies of Sciences 2017). Thus, for each of the models, age, sex, tobacco use status, anxiety, and depression were entered in Step 1,

Table 1. Sociodemographic and clinical characteristics by cannabis use frequency (N¼ 109).

Full Sample (n¼ 109)

No Current Use (n¼ 9)

Less than Monthly Use (n¼ 38 )

A Few Times per Month (n¼ 14)

A Few times per Week (n¼ 16)

Daily or Almost Daily (n¼ 32 )

Variable N (SD) N (SD) N (SD) N (SD) N (SD) N (SD)

Gender Male 48 (44.0) 4 (44.4) 16 (42.1) 5 (35.7) 10 (62.5) 13 (40.6)

Income (USD) < 10K 8 (7.3) 2 (22.2) 3 (7.9) 2 (14.3) 0 (0) 1 (3.1) 10–25K 24 (22) 0 (0) 7 (18.4) 4 (28.6) 4 (25) 9 (28.1) 25–50K 31 (28.4) 3 (33.3) 11 (28.9) 3 (21.4) 2 (12.5) 12 (37.5) 50–75K 20 (18.3) 1 (11.1) 7 (18.4) 3 (21.4) 3 (18.8) 6 (18.8) 75–100K 16 (14.7) 2 (22.2) 6 (15.8) 2 (14.3) 4 (25) 2 (6.3) > 100K 10 (9.2) 1 (11.1) 6 (15.8) 0 (0) 3 (18.8) 2 (6.3)

Education <High School 2 (1.8) 0 (0) 1 (2.6) 0 (0) 0 (0) 1 (3.1)

High School or GED 11 (10.1) 1 (11.1) 3 (7.9) 1 (7.1) 2 (12.5) 4 (12.5) Some College 47 (43.1) 6 (66.7) 14 (36.8) 9 (64.3) 6 (37.5) 12 (37.5) Technical School/

Associates Degree 6 (5.5) 0 (0) 3 (7.9) 0 (0) 0 (0) 3 (9.4)

Four-Year College 30 (27.5) 2 (22.2) 12 (31.6) 2 (14.3) 6 (37.5) 8 (25) Some Beyond College/

Professional 13 (12.0) 0 (0) 3 (7.9) 2 (14.3) 2 (12.5) 4 (12.5)

Race Black 6 (5.5) 0 (0) 2 (5.3) 1 (7.1) 1 (6.3) 2 (6.3) White 93 (85.3) 8 (88.9) 33 (86.8) 13 (92.9) 12 (75) 27 (84.4) Other 10 (9.2) 1 (11.1) 3 (7.9)) 0 (0) 3 (18.8) 3 (9.4)

Ethnicity Hispanic 10 (9.2) 0 (0) 3 (7.9) 2 (14.3) 2 (12.5) 3 (9.4)

Tobacco Use Status� Never 26 (23.9) 2 (22.2) 14 (36.8) 3 (21.4) 3 (18.8) 4 (12.5) Former 33 (30.3) 6 (66.7) 11 (28.9) 1 (7.1) 3 (18.8) 12 (37.5) Current, Occasional 24 (22) 0 (0) 6 (15.8) 4 (28.6) 5 (31.3) 9 (28.1) Current, Daily 26 (23.9) 1 (11.1) 7 (18.4) 6 (42.9) 5 (31.3) 7 (21.9)

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Age 26.97 (8.36) 30.56 (13.95) 27.67 (9.22) 23.14 (4.47) 26.75 (7.39) 27 (6.77) Anxiety Symptomsa 9.28 (5.47) 5 (5.27) 10.05 (5.39) 9.28 (5.94) 8.69 (4.89) 9.87 (5.42) Depression Symptomsb 26.76 (11.41) 20.11 (7.42) 28 (11.43) 30.71 (12.83) 24.94 (12.15) 26.34 (10.93) Pain-Related Interferencec 14.48 (9.6) 7.22 (6.34) 14.29 (9.61) 13 (8.83) 15.25 (9.8) 17.03 (9.9) Past-Month Pain Severityd 2.84 (0.96) 2.22 (0.83) 2.84 (0.94) 2.71 (0.99) 2.81 (1.11) 3.1 (0.89) DI – Avoidancee� 9.4 (3.48) 7.33 (1.73) 8.42 (3.28) 10.43 (4.05) 10.31 (3.62) 10.25 (3.37)

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