Integrated cognitive behavioral therapy for cannabis use and anxiety disorders:
Rationale and development
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 involv-
ing 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 treat-
ment termination predicts greater post-treatment cannabis use and re-
lated 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)isatrans-
diagnostic anxiety CBT that addresses several anxiety disorders
simultaneously by addressing False Safety Behaviors (FSB), or be-
haviors 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 mainte-
nance 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 treat-
ment 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 with-
drawal), resulting in a positive feedback loop between anxiety and can-
nabis 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 Treat-
ment Enhancement (CREATE) project is to compare motivation en-
hancement 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 puta-
tive mechanisms (e.g., cannabis use motives, FSB use) by which
treatment improves outcomes.
Participants (N = 60) will be recruited through our ongoing ﬂow of
patients, as well as through advertisements and community outreach.
Eligibility criteria include: (a) DSM-5 CUD; (b) co-occurring DSM-5 anx-
iety disorder; (c) cannabis use to reduce anxiety; (d) cannabis as sub-
stance of choice for anxiety management; and (e) age of 18–65.
Exclusion criteria include: (a) severe comorbid SUD requiring in-
patient treatment; (b) history of schizophrenia, bipolar disorder,
rocognitive disorder, or intellectual disability; (c) high suicide risk;
(d) prior simultaneous CBT for CUD and anxiety disorders; (e) legally
mandated for treatment; and (f) intent to participate in additional anx-
iety or SUD treatment during the study. Concurrent use of psychotropic
medications is permitted as long as patients have been on a stable dose
for at least three months prior to enrollment and they are willing to re-
main on a stable dose. Additionally, participants must be capable and
willing to adhere to study protocol.
Prospective participants will undergo a prescreening (assessing can-
nabis use, anxiety, motivation to quit cannabis and reduce anxiety, and
other inclusion/exclusion criteria) and will be brought in for a baseline
clinical interview if they appear eligible. Eligible participants will pro-
vide informed consent prior to enrollment. Enrolled participants will
be randomized to either ACCT or MET-CBT using urn randomization
(Stout, Wirtz, Carbonari, & Del Boca, 1994) by gender, age, cannabis
use frequency, and CUD and anxiety disorder severity.
Addictive Behaviors 39 (2014) 495–496
0306-4603/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
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