Abstract
Background/purpose:
Cannabis tolerance breaks, or T-breaks, are believed to benefit users by decreasing tolerance levels to cannabis. However, no prior research, to our knowledge, has compared the effects of T-breaks and other use breaks on cannabis use patterns and outcomes. The current study examined whether the occurrence of cannabis use breaks (tolerance and other use breaks), or the duration of these breaks, is associated with changes in hazardous cannabis use (CUDIT-R), CUD severity, cannabis use frequency, and withdrawal symptoms over a 6-month follow-up.
Methods:
Young adult recreational cannabis users (N=170, 55.9% female, Mean age=21 yo) completed baseline and on time 6-month assessments of hazardous cannabis use (CUDIT-R), CUD severity, cannabis use frequency, and withdrawal symptoms. The occurrence of cannabis use breaks and the duration of these breaks during the intervening period was assessed at 6 months.
Results:
Taking a T-break was associated with an increase in hazardous cannabis use and CUD severity at 6 months. When considering cannabis use breaks for other reasons, a longer break was associated with a significant decrease in hazardous cannabis use (CUDIT-R), CUD severity, and cannabis use frequency at 6 months.
Conclusion:
Findings from our study suggest users who take a T-break may be at greater risk for problematic cannabis use. In addition, taking a longer cannabis use break for other reasons may have beneficial effects on cannabis-related outcomes. The ability to abstain from cannabis for other reasons may be protective while individuals who take T-breaks may be important targets for intervention and prevention.
Keywords: Cannabis, Tolerance break, T-break, Hazardous use, Recreational, Young adults
1.1. Introduction
Cannabis is the most commonly used substance, after alcohol, and rates of hazardous use, and cannabis use disorders (CUDs), have steadily increased in recent years (Hamilton et al., 2019). In 2021, young adult (19–30) cannabis use reached historically high prevalence levels in the United States since first documented in 1988, with 11% reporting daily cannabis use, 29% reporting cannabis use in the past 30 days, and 43% reporting cannabis use in the past year (Patrick et al., 2022). High levels of exposure to cannabis is associated with negative outcomes, such as impairments in driving and cognition, development of substance use disorders, and greater prevalence of health-related, psychiatric, and psychosocial problems (Blanco et al., 2016; Hall and Degenhardt, 2014; Volkow et al., 2014). Further, frequent use of cannabis may lead to the development of tolerance to the impairing effects of delta-9-tetrahydrocannabinol on cognition, psychomotor function, and subjective intoxication (Hart et al., 2010; Ramaekers et al., 2011, 2009). Prior research indicates that use frequency quickly impacts the endocannabinoid system, including the downregulation of CB1 receptors among users (Curran et al., 2016; Ramaekers et al., 2020). However, research has shown after only two days of monitored abstinence, CB1 receptor density begins to normalize upon termination of cannabis use and may continue to increase over time (D’Souza et al., 2016). Notably, withdrawal symptoms typically begin within 1–3 days of abstinence, with peak effects observed within 2–6 days (Budney et al., 2003). These symptoms can interfere with daily functioning in addition to serving as a negative reinforcer that drives ongoing use (Allsop et al., 2012). Understanding how cannabis users manage their developing tolerance and subsequent withdrawal is key to identifying risk factors for problematic cannabis use onset.
Online resources are a primary educational source for cannabis users with regards to recommended strains, quantities, and behavioral approaches to managing cannabis use. One strategy recommended ubiquitously across websites to manage cannabis use patterns is a “tolerance break” or a “T-break.” A google search for “cannabis T-break” resulted in over 36,000,000 hits (December, 2022). Based on a review of the above websites (“Leafly,” n.d., “Rise Cannabis,” n.d., “WebMD,” n.d.), we defined a T-break for the purposes of this study as an intentional and temporary period of abstinence from cannabis with the primary goal of reducing tolerance levels so that a smaller amount of cannabis is needed to achieve the same high when use is resumed. Unlike quit attempts (“Practice Quitting Programs,” n.d.), T-breaks are generally done without the desire to quit and with the intention of resuming cannabis use after the break. Reasons for T-breaks vary but generally focus on an intentional break to mitigate the effects of heavier cannabis use on the endocannabinoid system, dysregulation of CB1 receptors, decreasing heavier use patterns, and preventing CUD (“Leafly,” n.d., “WebMD,” n.d.). Recommended length of time varies considerably from 2–5 days, 5–6 days, or up to 4 weeks (“Happy Valley,” n.d., “Healthline,” n.d., “Leafly,” n.d., “PotGuide,” n.d., “Rise Cannabis,” n.d., “VeriLife,” n.d., “WebMD,” n.d., “Weed Maps,” n.d.), but there is little to no scientific basis for these durations. Withdrawal symptoms are often described on the websites, and strategies for monitoring and dealing with withdrawal symptoms are frequently outlined. Despite the specificity and consistency of T-break recommendations in online resources, there is a dearth of scientific research on the topic. Only one other study has addressed T-breaks in the scientific literature. Fontana and colleagues examined the feasibility of a self-directed T-break Guide in frequent recreational users who were interested in taking a T-break. Those who used the guide “a lot”, compared to those who did not use the Guide or used the Guide “some,” were more likely to complete a 21-day tolerance break (Fontana et al., 2023). This also suggests that recreational cannabis users are actively seeking resources and engaging in T-breaks.
The underlying assumption across online resources and communities is that T-breaks have a beneficial effect by decreasing patterns of hazardous cannabis use. However, individuals may also take a cannabis use break for other reasons. Individuals may intentionally abstain from cannabis for a temporary period of time for financial constraints, exam weeks, upcoming drug testing, travel, work related reasons, or limited access. It is unclear if these more general cannabis use breaks (i.e., not motivated by tolerance symptoms), result in similar outcomes as T-breaks in cannabis users. It is also unclear if those who take tolerance breaks are different from those who take cannabis use breaks for other reasons. Given the existing gaps in the literature, the purpose of this study is to examine the occurrence of cannabis use breaks, both for tolerance and for other reasons, in a sample of young adult recreational cannabis users over a 6-month period of follow-up. Specifically, we examine whether the occurrence of cannabis use breaks (tolerance and other use breaks), or the duration of these breaks, is associated with changes in hazardous cannabis use, CUD severity, cannabis use frequency, and withdrawal symptoms over the follow-up.
2.1. Material and Methods
2.1.1. Sample and procedures
Young adult recreational cannabis users, living in the Northeastern United States, were recruited via flyers, social media, and word of mouth. These assessments were collected as part of a larger longitudinal study on patterns of recreational cannabis use among individuals living in a state where cannabis use was illegal. Advertisements sought to recruit participants at varying frequencies of cannabis use (e.g., ever used, occasional, frequent cannabis use). Included participants had to be between 18–30 years of age, report using cannabis recreationally at least once per month for the past six months, and could not meet criteria for any current or past severe substance use disorder, except for nicotine. Half of participants recruited were occasional users (less than three occasions of use per week) and the other half were frequent users (three or more occasions of use per week) (Desrosiers et al., 2014; van der Pol et al., 2013). In addition to other study assessments, eligible participants completed demographic surveys, the Cannabis Use Disorder Identification Test-Revised (CUDIT-R) and research staff conducted interviews to assess cannabis use disorder (CUD) severity, cannabis use frequency, and withdrawal symptoms at baseline and 6 months later. All study protocols were approved by the Institutional Review Board and participants provided written informed consent prior to starting the study. Of the 226 who completed baseline, 56 participants had incomplete data or late completion of follow-up, and were not included in the analysis. Participants that were included did not differ significantly from the participants that were not included in the analyses with respect to age (t(228)=.104, p=.918), sex (t(228)=−.328, p=.743), baseline CUDIT-R scores (t(226)=1.290, p=.198), CUD severity (t(228)=1.287), p=.199), depressive symptoms (t(228)=.496, p=.620), or age of first cannabis use (t(227)=−.538, p=.591). The final analytic sample included 170 participants (51.2% occasional users, 48.8% frequent users).
2.2. Measures
2.2.1. The Cannabis Use Disorder Identification Test – Revised
The CUDIT-R was used to assess hazardous cannabis use over the past 6 months. It consists of 8 items that are scored from 0 (never) to 4 (daily or almost daily) regarding consumption, problems, dependence, and psychological features (Adamson et al., 2010). A score of 8 or more indicates hazardous cannabis use, while scores of 12 or more are likely to indicate cannabis use disorder. Cronbach’s alpha for the study was 0.73 (baseline) and 0.69 (6-month).
2.2.2. Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (SCID)
The SCID is the most widely used, reliable and well-validated, structural clinical assessment tool for the DSM-5 diagnostic criteria (First, 2015). The SCID was administered by trained research assistants and supervised by a clinical psychologist. Participants were asked, “at any point in the last 6 months have you had any withdrawal symptoms, in other words felt sick when you cut down or stopped using?” and able to endorse any specific symptoms they experienced from a list of known withdrawal symptoms. CUD module were summed to assess current CUD severity at baseline and the 6-month follow-up. Current withdrawal symptoms from the CUD module were summed at baseline and the 6-month follow-up.
2.2.3. History and Current Cannabis Use Patterns
The frequency of cannabis use was assessed by asking participants about their current cannabis use, “How often do you use marijuana?”. Responses were coded for occasions per week. Participants were also asked, “At what age did you first use marijuana?”. These items were collected at baseline and at the 6-month follow-up.
2.2.4. Cannabis Use Breaks
Participants were asked as part of a semi-structured interview, “Have you taken any T-breaks (i.e., have you purposefully tried to decrease your tolerance levels to cannabis by cutting down or stopping your use?” If participants indicated that they stopped cannabis use for a T-break was (yes/no) participants were asked, “How long was your longest T-break over the past 6 months?” Participants were subsequently asked, “Have you cut down or stopped your marijuana use for reasons other than a T-break?” If a cannabis use break (i.e., they indicated that they stopped use) for other reasons was endorsed (yes/no) participants were asked, “How long was your longest period of cutting down or stopping marijuana use over the last 6 months?” Duration of a cannabis use break was standardized as total number of weeks. If a cannabis use break for other reasons was endorsed, participants were asked, “Was this for work related reasons? (e.g., starting a new job, drug testing, etc.)”, “For relationship reasons? (e.g., family, significant other, friends, roommate)”, “For sport, athletic, or competition reasons?”, and “For some other reason?” with an open-ended response option to indicate the other reason. Categories for other use breaks were then coded by a group of research assistants as falling under drug test, financial, mental health, no access, personal, physical health, relationship, school, sport, or work. Incongruent ratings were reviewed as a group with the PI and assignment was done by group consensus. Participants could endorse multiple reasons for a use break. These items were collected only at 6 months. In some cases, participants endorsed a T-break and a cannabis use break for other reasons on separate occasions. Participants were coded for both in those instances.
2.2.5. Beck Depression Inventory (BDI)
The BDI was used to assess the existence and severity of depressive symptoms over the past week. This is a 21-item measure with response options ranging from 0 to 3. Total scores of depressive symptoms ranging from 0 to 63 were determined by the summation of all 21 items. Severity of depressive symptoms can range from minimal (0 to 9), mild (10 to 18), moderate (19 to 29), and severe (30 to 63) (Beck et al., 1988). The BDI has been found to be a valid and reliable measure across different populations and countries (Fydrich et al., 1992). Cronbach’s alpha for the present study was .91.
3.1. Results
3.1.1. Statistical Analyses
Multiple regression analyses were conducted to examine the association between cannabis use breaks (tolerance and other) and length of use break (tolerance and other) with CUDIT-R, CUD severity, cannabis use frequency, and withdrawal symptom scores at 6 months. The regression model included both T-break and other breaks variables in the same model. Sex, age, cannabis use status, and age of first cannabis use were included as covariates in all models. Baseline scores for CUDIT-R, CUD severity, cannabis use frequency, and withdrawal symptoms were controlled for when predicting each respective longitudinal outcome. Alpha levels for all statistical procedures were set at .05. All statistical analyses were conducted using IBM SPSS Version 27.
3.1.2. Sample Descriptives and Cannabis Use Breaks
The average age of the sample was 21 years old, 55.9% female (44.1% male), and 70.6% self-identified as Caucasian (9.4% African American, 6.5% Asian, 8.8% Hispanic, and 4.7% other ethnicity) (see Table 1). Over the course of 6 months following baseline assessment, 58.2% of the sample reported taking a cannabis use break of any kind, 17.1% reported taking a T-break in the 6-month period, and 51.8% took a cannabis use break for other reasons in the same period. 10.3% of occasional users reported taking a T-break, while 24.1% of frequent users reported taking a T-break in the 6-month period. 48.3% of occasional users reported taking a cannabis use break for other reasons, and 55.4% of frequent users reported taking a cannabis use break for other reasons during the 6-month period of follow-up. The average length of time reported for a T-break was 2.5 weeks while cannabis use breaks for other reasons were 8 weeks on average (see Table 2). Participants reported taking cannabis use breaks for a diverse set of reasons. The most frequent reasons given were work (to focus or accomplish specific tasks at work, because they believed it was negatively impacting work performance), financial reasons, no or limited access to cannabis, relationship reasons (friends, significant other, or family raised issues), and for personal reasons (“just felt like it was time”).
Table 1.
Descriptive Statistics.
| Total N = 170 | Tolerance Break N=29 |
Other Use Break N = 88* | No Break N = 71 | |
|---|---|---|---|---|
|
| ||||
| Sex n (%) | ||||
| Female | 95.0 (55.9) | 14.0 (48.3) | 48.0 (54.5) | 41.0 (57.7) |
| Male | 75.0 (44.1) | 15.0 (51.7) | 40.0 (45.5) | 30.0 (42.3) |
| Age (yrs) | ||||
| M (SD) | 21.0 (2.4) | 20.1 (2.2) | 21.0 (2.4) | 21.2 (2.4) |
| Race/Ethnicity n (%) | ||||
| Caucasian | 120.0 (70.6) | 19.0 (65.5) | 59.0 (67.0) | 54.0 (76.1) |
| African American | 16.0 (9.4) | 3.0 (10.3) | 8.0 (9.1) | 7.0 (9.9) |
| Asian | 11.0 (6.5) | 1.0 (3.4) | 6.0 (6.8) | 4.0 (5.6) |
| Hispanic | 15.0 (8.8) | 3.0 (10.3) | 12.0 (13.6) | 3.0 (4.2) |
| Other | 8.0 (4.7) | 3.0 (10.3) | 3.0 (3.4) | 3.0 (4.2) |
| Employment Status n (%) | ||||
| Full-time | 24 (14.1) | 1 (3.4) | 14 (15.9) | 10 (14.1) |
| Part-time | 82 (48.2) | 12 (41.4) | 45 (51.1) | 30 (42.3) |
| Unemployed/Not in work force | 64 (37.7) | 16 (55.1) | 29 (33.0) | 31 (43.7) |
| Years of Education Completed | ||||
| M (SD) | 13.8 (1.6) | 13.1 (1.4) | 13.8 (1.6) | 13.9 (1.8) |
| Beck Depression Inventory | ||||
| M (SD) | 5.9 (7.0) | 3.8 (4.2) | 5.7 (5.8) | 6.5 (8.5) |
| None n (%) | 132 (77.7) | 26 (89.7) | 70 (79.5) | 53 (74.6) |
| Mild n (%) | 30 (17.7) | 3 (10.3) | 16 (18.2) | 12 (18.4) |
| Moderate n (%) | 4 (2.3) | 0 (0.0) | 1 (1.2) | 3 (2.8) |
| Severe n (%) | 4 (2.3) | 0 (0.0) | 1 (11) | 3 (4.2) |
|
Age of Cannabis Use Onset (yrs) | ||||
| M (SD) | 16.8 (2.0) | 16.4 (2.0) | 16.9 (1.8) | 16.7 (2.2) |
| Cannabis Use Status n (%) | ||||
| Occasional | 87.0 (51.2) | 9.0 (31.0) | 42.0 (47.7) | 43.0 (60.6) |
| Frequent | 83.0 (48.8) | 20.0 (69.0) | 46.0 (52.3) | 28.0 (39.4) |
| CUDIT-R baseline | ||||
| M (SD) | 8.6 (4.9) | 9.8 (4.2) | 9.4 (5.1) | 7.5 (4.6) |
|
Cannabis Use Frequency Baseline (per week) | ||||
| M (SD) | 3.3 (3.5) | 3.7 (2.7) | 3.4 (3.6) | 2.9 (3.2) |
| CUD Severity baseline | ||||
| M (SD) | 3.7 (3.9) | 4.5 (3.8) | 3.8 (3.8) | 3.1 (3.9) |
| No Longer Using Cannabis at 6 Months n (%) | 14 (8.2) | 3 (10.3) | 11 (12.5) | 3 (4.2) |
indicates 18 participants took cannabis breaks for both tolerance and other reasons. Note: CUDIT-R – Cannabis Disorder Identification Test-Revised, DSM-5 CUD Severity – The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Cannabis Use Disorder Criteria; sum of all 0, 1, 2 coded criteria.
Table 2.
Length of cannabis use breaks and reasons for other use break.
| Average length of cannabis use break (weeks) | |
|---|---|
|
| |
| Average length of tolerance breaks a | |
| M (SD) | 2.5 (2.4) |
| [Range] | [0.3 – 12.0] |
| Average length of other use breaks b | |
| M (SD) | 8.0 (6.2) |
| [Range] | [0.6 – 24.0] |
| Other Reasons* n(%): | |
| Drug Test | 2.0 (2.3) |
| Financial | 15.0 (17.0) |
| Mental health | 9.0 (10.2) |
| No access | 15.0 (17.0) |
| Personal | 14.0 (15.9) |
| Physical health | 7.0 (8.0) |
| Relationship | 10.0 (11.4) |
| School | 12.0 (13.6) |
| Sport | 0.0 (0.0) |
| Work | 25.0 (28.4) |
Average length of cannabis use break for tolerance reasons in weeks; N =28
Average length of cannabis use break for other reasons in weeks; N=86
In some instances, more than one reason was given for a break. Thus, total percent > 100.
3.1.3. Tolerance and other cannabis use breaks
Taking a tolerance break between baseline and 6 months was associated with a significant increase in CUDIT-R scores at 6 months (b=1.992, t(162)=2.819, p=.005), controlling for all covariates, and hazardous use at baseline. Taking a tolerance break between baseline and 6-months was associated with a significant increase in CUD severity at six months (b=1.527, t(162)=2.462, p=.015), controlling for all covariates, and CUD severity at baseline. However, taking a tolerance break between baseline and 6 months was not associated with cannabis use frequency or withdrawal symptoms at 6 months. There were no associations between taking a break for other reasons between baseline and 6-months and CUDIT-R scores, CUD severity, cannabis use frequency, or withdrawal symptoms at 6 months (see Table 3).
Table 3.
Associations between cannabis use breaks and cannabis-related outcomes.
| CUDIT-R 6-months | CUD Severity 6 months | Use Frequency 6- months | Symptoms 6- months | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
||||||||||||||||
|
Variabl
e |
B | β | P | R2 | B | β | P | R2 | B | β | P | R2 | B | β | P | R2 |
|
| ||||||||||||||||
| Constant | 10.4 35 |
<.001 * | .5 06 |
6.9 98 |
.007 * | .3 08 |
6.5 91 |
.0 78 |
.1 28 |
.7 81 |
.355 | .1 65 |
||||
| Sex | 1.07 0 |
.11 1 |
.046 * | − .61 7 |
− .0 87 |
.185 | − .36 0 |
− .0 39 |
.5 92 |
− .2 77 |
− .1 32 |
.070 | ||||
| Age | − .203 |
− .1 00 |
.084 | − .16 7 |
− .1 11 |
.102 | − .05 0 |
− .0 26 |
.7 32 |
− .0 42 |
− .0 94 |
.208 | ||||
| Cannabis use status | .610 | .06 4 |
.313 | 1.27 7 |
.18 1 |
.014 * | .775 | .086 | .3 50 |
.2 14 |
.1 02 |
.174 | ||||
| Age of first cannabis use | − .210 |
− .0 87 |
.136 | − .14 2 |
− .8 08 |
.248 | − .20 9 |
− .09 1 |
.2 38 |
.0 19 |
.0 35 |
.639 | ||||
| CUDIT-R baseline | .622 | .63 1 |
<.00
1 * |
− | − | − | − | − | − | − | − | − | ||||
| CUD severity baseline | − | − | − | .382 | .42 2 |
<.00
1 * |
− | − | − | − | − | − | ||||
| Use frequency baseline | − | − | − | − | − | − | .358 | .27 4 |
.00
3 * |
− | − | − | ||||
| Sum of Withdrawal Symptoms baseline | − | − | − | − | − | − | − | − | − | .3 37 |
.3 29 |
<.00
1 * |
||||
| Tolerance break | 1.99 2 |
.1 57 |
.005 * | .5 35 |
1.52 7 |
.16 3 |
.015 * | .3 39 |
1.5 46 |
.12 9 |
.0 91 |
.1 44 |
− .0 14 |
− .0 05 |
.946 | .1 68 |
| Other break | .623 | .0 65 |
.235 | .461 | .06 6 |
.310 | − .31 9 |
− .0 35 |
.6 31 |
.1 08 |
.0 52 |
.476 | ||||
Values in bold are significant at p<.05; N = 170. Note: Covariates reported at first level without use break variables. CUDIT-R - Cannabis Use Disorder Identification Test-Revised; DSM-5 CUD Severity – The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Cannabis Use Disorder Criteria; sum of all 0, 1, 2 coded criteria.
3.1.4. Length of tolerance and other use breaks
The length of a tolerance break between baseline and 6 months was not associated with CUDIT-R scores, CUD severity, cannabis use frequency, or withdrawal symptoms at 6 months. However, when considering cannabis use breaks for other reasons between baseline and 6 months, a longer break was associated with a significant decrease in CUDIT-R scores at 6 months (b=−.152, t(89)=−2.724, p=.008), controlling for all covariates, and CUDIT-R scores at baseline. The length of a cannabis use break between baseline and 6 months was associated with a significant decrease in CUD severity at 6 months (b=−.117, t(89)=−2.084, p=.040), controlling for all covariates, and CUD severity at baseline. A longer break for other reasons between baseline and 6 months was also associated with a significant decrease in cannabis use frequency at 6 months (b=−.241, t(89)=−3.190, p=.002), controlling for all covariates, and cannabis use frequency at baseline. There were no associations between the length of a cannabis use break for other reasons between baseline and 6 months and withdrawal symptoms at 6 months (Table 4).
Table 4.
Associations between length of cannabis use breaks and cannabis-related outcomes.
| CUDIT-R 6-months | CUD Severity 6-months | Use Frequency 6-months | Symptoms 6-months | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
||||||||||||||||
| Variable | B | β | P | R2 | B | β | P | R2 | B | β | p | R2 | B | β | P | R2 |
|
| ||||||||||||||||
| Constant | 14.1 30 |
<.001 * | .5 20 |
13.5 78 |
<.00
1 * |
.3 30 |
14.7 19 |
.00
8 * |
.1 80 |
.3 89 |
.608 | .2 06 |
||||
| Sex | 1.46 1 |
.159 | .034 * | − .304 |
− .0 39 |
.656 | .075 | .00 8 |
.93 7 |
− .2 26 |
− .1 17 |
.100 | ||||
| Age | − .222 |
− .1 12 |
.146 | − .206 |
− .1 23 |
.172 | − .37 8 |
− .1 78 |
.07 7 |
− .0 24 |
− .0 60 |
.410 | ||||
| Cannabis use status | .393 | .043 | .606 | 2.000 | .25 7 |
.007 * | .738 | .07 5 |
.51 6 |
.2 73 |
.1 43 |
.054 | ||||
| Age of first cannabis use | − .359 |
− .14 5 |
.058 | −.491 | − .23 6 |
.010 * | − .30 4 |
− .1 15 |
.24 7 |
.0 15 |
.0 31 |
.677 | ||||
| CUDIT-R baseline | .588 | .63 4 |
<.00
1 * |
− | − | − | − | − | − | − | − | − | ||||
| CUD severity baseline | − | − | − | .361 | .36 3 |
<.00
1 * |
− | − | − | − | − | − | ||||
| Use frequency baseline | − | − | − | − | − | − | .42 6 |
.31 4 |
.007
* |
− | − | − | ||||
| Sum of Withdrawal Symptoms baseline | − | − | − | − | − | − | − | − | − | .3 49 |
.3 74 |
<.001 * | ||||
|
| ||||||||||||||||
| Length of tolerance break | −.033 | − .00 9 |
.903 | .5 57 |
−.170 | − .05 5 |
.540 | .3 62 |
.07 2 |
.0 18 |
.84 8 |
.2 65 |
− .0 46 |
− .0 67 |
.361 | .2 11 |
| Length of other break | − .152 |
− .21 1 |
.008 * | − .117 |
.- 19 4 |
.040 * | − .24 1 |
− .31 3 |
.002
* |
− .0 04 |
− 02 6 |
.720 |
||||
Values in bold are significant at p<.05; N = 97. Note: Covariates reported at first level without use break variables. CUDIT-R - Cannabis Use Disorder Identification Test-Revised; DSM-5 CUD Severity – The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Cannabis Use Disorder Criteria; sum of all 0, 1, 2 coded criteria.
4.1. Discussion
This study examined the occurrence of cannabis use breaks in young adult recreational cannabis users over 6 months of follow-up. Use breaks may be motivated by the desire to decrease tolerance (T-breaks) or for other situational constraints such as work, relationships, or travel (other use breaks). Despite common beliefs about their efficacy in reducing CUD and cannabis use risk, T-breaks were associated with increases in hazardous cannabis use and CUD severity but not self-reported changes in use frequency or withdrawal symptoms over 6 months. Unlike T-breaks, taking cannabis use breaks for other reasons was not associated with any cannabis use outcomes. These findings suggest taking a T-break may be a marker of increased risk for problematic outcomes in recreational cannabis users. It is important to note that while the motivation behind T-breaks is clearly a sign of hazardous cannabis use and CUD severity, many of the content areas of other cannabis use breaks are similarly related to hazardous and problematic use (work, financial, relationships, mental or physical health).
Online forums frequently refer to the length of time as an important determinant of the success of a T-break. Recommendations vary widely from 2 days (“Green Health Docs,” n.d., “Leafwell,” n.d., “Weed Maps,” n.d.), 5 days (“Happy Valley,” n.d., “VeriLife,” n.d.), 2 weeks (“Leafwell,” n.d., “PotGuide,” n.d.), 3 weeks (“Healthline,” n.d., “WebMD,” n.d.), or up to 4 weeks (“Green Health Docs,” n.d.). To test the relevance of length of time, we examined whether length of time of T-breaks or other use breaks was associated with cannabis use outcomes. T-breaks in our sample lasted on average 2.5 weeks which is a duration consistent with the average length of time described in online forums and suggests cannabis users may be following online recommendations. Breaks in cannabis use for other reasons were on average much longer (almost 2 months). Length of time for other use breaks was associated with decreases in hazardous cannabis use, CUD severity, and use frequency over a 6-month period. Length of time for T-breaks was not associated with changes in cannabis-related outcomes.
While 58% of the sample reported taking any type of break from cannabis use over the 6-month period, only 17% of the sample reported taking a T-break. This suggests that cannabis use breaks are a relatively frequent occurrence among recreational cannabis users, but that T-breaks are a rarer occurrence. Frequent cannabis users were more likely to report taking a T-break. However, it is unclear if the higher likelihood of a tolerance break among frequent users is due to issues related to more prevalent tolerance or more familiarity with cannabis culture and online forums that recommend T-breaks. It is also important to note that T-breaks were not exclusive to frequent users. Almost one-third of the T-breaks reported were taken by baseline occasional users, and the analyses controlled for cannabis use status, suggesting that T-breaks are a risk factor regardless of use frequency status. Despite expectations that cannabis use breaks would be associated with withdrawal symptoms, we did not find any associations between T-breaks or other breaks with withdrawal symptoms at 6 months. However, withdrawal symptoms were likely mitigated by continued cannabis use in the majority of participants. 92% of participants were actively using cannabis at the time of the 6-month assessment. Three participants in the T-break group quit using cannabis during those 6 months. However, all three indicated that they quit after taking a cannabis use break for other reasons, not as a result of the T-break. It may be that T-breaks are not motivated quit attempts, rather attempts to reduce or regulate one’s use patterns. More research is needed on motivations for T-breaks vs other cannabis use breaks and how this relates to reduction or cessation of cannabis use. Future research should also examine acute withdrawal symptoms in individuals taking T-breaks versus other breaks and what the proximal effects of T-breaks and other breaks are on cannabis use patterns, withdrawal, and length of abstinence. In addition, future studies should examine whether T-breaks are associated with normalization of CB1 receptors that has been identified in prior research of cannabis abstinence (D’Souza et al., 2016).
This study is the first to assess whether cannabis use breaks (T-break and other use breaks) and length of cannabis use breaks are associated with important markers of hazardous and clinical cannabis use among young adult recreational cannabis users, providing important insight on the implications of T-breaks for users. However, the current study has limitations that should be considered in the interpretation of findings. Reports of cannabis use breaks and cannabis use were self-reported and retrospective. While the reporting period was relatively brief (6 months), the nature of the assessment may introduce bias in reported motives, length of time, or even occurrence of the break. Future research should assess more precise amounts and potency of cannabis use before and after breaks. Additionally, withdrawal symptoms were assessed consistent with CUD criteria (past 6 months) and did not ask specifically about the same time period as the cannabis use break. Participants were encouraged to refer to personal calendars to verify information as needed. Recreational cannabis use was not legal at the time of the study and it is unclear whether legalization impacts use patterns related to use breaks for other reasons (e.g., access). The impacts of cannabis use breaks found in our study may be specific to young adult users of recreational cannabis and may not generalize to impacts across the lifespan (e.g., younger and/or older populations) or medicinal uses. Finally, the sample size, particularly those who took T-breaks, was relatively smaller compared to other groups. Additional research is needed that targets larger samples of cannabis users who take T-breaks.
5.1. Conclusions
Despite popular belief, findings from our study suggest users who take a T-break may be at greater risk for problematic cannabis use patterns. Taking a longer cannabis use break for other reasons may have beneficial effects on cannabis-related outcomes, suggesting the ability to abstain from cannabis for other reasons may be protective. Motivation to take a T-break may be a notable target for intervention and prevention. Future studies should examine the physiological mechanisms that underlie the benefits of longer use breaks, including tolerance and other reasons, and neuroadaptations to CB1 receptor density. These findings may inform current online recommendations on the effectiveness of cannabis use breaks to decrease tolerance and prevent increasing hazardous cannabis use.
Highlights.
The majority of recreational cannabis users report taking a use break over a 6-month period.
Tolerance breaks (T-breaks) are associated with increasingly hazardous cannabis use over 6 months in young adult recreational cannabis users.
Longer cannabis use breaks taken for reasons other than tolerance may reduce hazardous cannabis use.
Role of Funding Source:
This work was supported by the National Institute on Drug Abuse (K08 DA029641, R01 DA039924, F31 DA056066) and through a supplement from NIH\ORWH. The funding source had no influence on the study design, data collection, analysis, interpretation, or the decision to submit the article for publication.
Footnotes
Conflict of Interest: No conflict declared.
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