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. Author manuscript; available in PMC: 2023 Jan 25.
Published in final edited form as: Drug Alcohol Depend. 2022 Jul 29;238:109588. doi: 10.1016/j.drugalcdep.2022.109588

Distress Tolerance and Reactivity to Negative Affective Cues in Naturalistic Environments of Cannabis-Using Emerging Adults

Kathryn S Gex a, Kevin M Gray a, Aimee L McRae-Clark a,b, Michael E Saladin c, Rachel L Tomko a
PMCID: PMC9875670  NIHMSID: NIHMS1860131  PMID: 35932750

Abstract

Background.

Distress tolerance (DT) has been implicated as an important factor in the experience of negative affect (NA) and cannabis craving. However, previous research is limited by its use of laboratory paradigms that may not replicate in naturalistic settings. The current study examined how DT influenced reactivity to NA cues in daily life in a sample of frequent (≥3 times per week) cannabis-using emerging adults (age 18-21).

Methods.

Using cue-reactivity ecological momentary assessment (CREMA), 63 (54% female; 85.7% white; Mage = 19.62) participants reported on their cannabis craving and affect (sadness, relaxation) four semi-random times per day for two weeks (56 possible CREMA sessions/participant). We assessed affect and cannabis craving before and after exposure to neutral and NA cues. Multilevel modeling was used to examine within- and between-participant effects of cues, DT, and sex, as well as within- and between-participant average pre-cue affect and craving, on post-cue affect and craving.

Results.

NA cues consistently predicted higher-than-normal post-cue sadness and lower relaxation, but not greater-than-normal post-cue craving. Cue type interacted with sex and DT to predict post-cue sadness, but not craving. Female participants and those reporting low DT reported higher sadness following NA cues compared to males and those with high DT, respectively.

Conclusions.

Frequent cannabis-using emerging adults differed in affect, but not cannabis craving, reactivity to NA cues as a function of sex and DT. Our results were partially consistent with prior human laboratory and CREMA research finding greater reactivity to NA cues among females and individuals with low DT.

Keywords: cue reactivity, ecological momentary assessment, cannabis craving, distress tolerance, affect

1. Introduction

Cannabis use is common among emerging adults (age 18-25) in the U.S. (Schulenberg et al., 2021), with 23% reporting past month use and 8% reporting daily use (Center for Behavioral Health Statistics and Quality, 2021). Regular cannabis-using individuals frequently report use as an effective way to relax/relieve stress and acutely alleviate emotional distress (Copeland et al., 2001; Green et al., 2003; Hathaway, 2003). Although some cannabis constituents, such as cannabidiol (CBD), can have anxiolytic effects (Gibson et al., 2021), regular cannabis use to cope with negative psychological and physiological states is associated with greater risk of developing cannabis use related problems and Cannabis Use Disorder (CUD) (Bujarski et al., 2012; Johnson et al., 2010). Thus, it is critical to understand individual-level and day-to-day level processes that interact to maintain high levels of use despite the potential for long-term problems in this high risk population.

Perceived distress tolerance (DT) appears to contribute to using to cope with negative psychological states (McHugh and Kneeland, 2019). Individuals with low DT believe their abilities to cope with distress are inferior and seek out the most rapid means to alleviate negative emotions (Bernstein et al., 2011; Leyro et al., 2010; Simons and Gaher, 2005). DT has demonstrated robust associations with depression (Ellis et al., 2010) and anxiety (Keough et al., 2010), and is negatively associated with cannabis use coping motives (i.e., use to cope with distress), cannabis craving when distressed, heavier cannabis use, CUD symptoms, and more severe withdrawal, and it is positively associated with cessation outcomes (Buckner et al., 2007; Bujarski et al., 2012; Dvorak and Day, 2014; Farris et al., 2016; Hasan et al., 2015; Potter et al., 2011; Zvolensky et al., 2009). Though both sex (referring to biological differences in males and females) and gender (referring to differences based in cultural/societal factors) and DT have generally been understudied in substance using populations (McHugh and Kneeland, 2019), DT appears to be strongly associated with more negative substance use outcomes in women (Hearon et al., 2011; Lehavot et al., 2014). While both men and women with low DT tend to report more cannabis related problems (Bujarski et al., 2012), women are more likely to report using to cope with negative affect (McHugh et al., 2013; Thornton et al., 2012).

Little is known about how DT influences acute reactivity to distressing tasks or cues among cannabis-using emerging adults. To our knowledge, only one study has examined this question directly. Buckner et al. (2019) randomized cannabis-using emerging adults to either a 3-minute distressing task (speak to a confederate/research assistant and try to make as favorable an impression as possible) or a neutral task (read a magazine at their own pace). Following the distressing task, cannabis-using participants with low DT reported greater distress and cannabis craving compared to those with high DT. This study used a laboratory paradigm, and it is unclear how these findings translate to users’ natural environments.

1.1. The Current Study

The current study utilized Cue-Reactivity Ecological Momentary Assessment (CREMA) (Warthen and Tiffany, 2009), a methodology combining intensive longitudinal assessment in participants’ natural environments with cue exposure via a mobile device, to examine the effect of sex and “trait” level DT on “state” level affect and cannabis craving following randomly administered negative affective (NA) cues. This study was an analysis of secondary outcomes. CREMA was designed to better capture contextual factors influencing cue-reactivity that may be difficult to simulate in a laboratory paradigm (Warthen and Tiffany, 2009). Initial CREMA research with cigarette smokers demonstrated findings consistent with human laboratory paradigms in terms of reactivity to stressful or NA cues (Tomko et al., 2020; Wray et al., 2015). Female smokers were more reactive to stressful/NA cues relative to male smokers, reporting greater stress, NA, and craving post-cue. To date, however, CREMA methodology has not been used to observe cue-reactivity in cannabis-using emerging adults in their natural environment.

The goals of the current study were to (1) extend research by applying CREMA methodology with cannabis-using emerging adults and evaluating reactivity to NA cues, and (2) investigate the effect of DT on NA cue reactivity. We first examined baseline associations between our variables of interest. Next, we examined the effects of NA cues and DT on post-cue affect (sadness, relaxation) and craving (general, coping-related). We hypothesized that, relative to neutral cues, NA cues would be associated with higher post-cue sadness and lower relaxation, and that low DT would be associated with higher-than-average sadness and lower-than-average relaxation following exposure to NA cues. We also expected that low DT would be associated with higher-than-average craving following NA cues. Finally, in line with CREMA research with cigarette smokers, we hypothesized that female participants would be more reactive to NA cues compared to males, and we extended this by investigating the interaction between sex and DT to predict post-cue affect and craving. See Figure 1 for conceptual models of our hypotheses.

Figure 1.

Figure 1.

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Conceptual Models of Hypotheses.

Note: Models represent primary hypotheses. Solid line ovals = “trait” variables measured at baseline. Solid line rectangles = “state” variables measured pre- and post-cue exposure in each CREMA session. Dotted line ovals = two-way interactions at the between-participant level. Dotted line rectangles = cross-level interactions.

2. Material and Methods

2.1. Participants

Participants were 63 non-treatment-seeking emerging adults (34 women, 54%) age 18-21 (M = 19.62, SD = 1.04). Participants were eligible to participate if they reported using cannabis at least 3 times per week over the past 30 days (Mdays used = 25.11, SD = 6.75) confirmed by a positive oral fluid cannabinoid test (Δ9-tetrahydrocannabinol, THC; Forensic Fluids Laboratories) or urine sample (assessing a semi-quantitative cannabinoid immunoassay). Participants could not be planning to quit or reduce their cannabis use in the next month, have a severe substance use disorder requiring higher level/immediate care, be currently enrolled in treatment for substance use, be pregnant or lactating, or have any severe condition that could interfere with study procedures. Participants completing the study entirely remotely also had to be accessible via videoconference, have access to a local UPS drop-off location, and own an iOS device for CREMA app use.1

2.2. Procedure

All procedures were approved by the Medical University of South Carolina Institutional Review Board. Participants were recruited via local multimedia campaigns. Interested individuals completed a brief phone screen, and those potentially eligible were scheduled for a baseline visit. Informed consent was obtained prior to initiating any study procedures. In-person participants completed a screening session during which they submitted a urine sample for cannabinoid analysis. Remote-only participants (amid COVID-19 precautions) submitted an oral fluid sample by mail2and time since they last used cannabisand time since they last used cannabis Eligible participants completed baseline assessments and were oriented to the CREMA protocol.

Participants selected four 2-hour time blocks during which a CREMA session would be randomly administered each day. CREMA sessions followed procedures similar to those of the initial study that developed and tested CREMA software on personal digital assistant (PDA) computers (see Warthen & Tiffany, 2009). In the current study, participants were provided an Apple iPhone or were asked to download the iOS compatible CREMA app to their personal iPhone (see Wray et al., 2015). At the beginning of each CREMA session, participants reported on their current affect, craving, any recent stressors, and time since they last used cannabis3 Then participants were shown one image cue for 10 seconds from one of three cue types: neutral, NA, or cannabis. Neutral and NA images were taken from the International Affective Picture System (IAPS; Lang et al., 2008) and cannabis images were taken from a previously validated cannabis cue reactivity task (Karoly et al., 2019). Each cue type was designed to be presented at least once per day in a random order (four total cues presented on a study day) and no cue images were repeated. For the current study, we only analyzed CREMA sessions in which a neutral or NA cue was administered. Following the cue, participants reported on their affect and craving again. Completed CREMA sessions (n = 2639) on average lasted 2 minutes and 39 seconds (or 2:39, SD = 01:58; Median = 2:01; Mode = 01:27, n = 35 sessions) and ranged between 0:43 and 14:35,4 and 134 CREMA sessions were started but not completed. On average, CREMA sessions were initiated approximately 3 minutes after the prompt, with a range of zero seconds (immediately) up to 1 hour and 56 minutes.5

2.3. Variables

2.3.1. Sex and Gender.

Sex and gender were both assessed once at baseline via “what is your gender identity?” and “what sex were you assigned at birth, meaning on your original birth certificate?” For the first item, participants could select “male,” “female,”, “trans male/trans man,” “trans female/trans woman,” or “different identity” and were asked to specify. For the second item, participants could select either “male” or “female.”

2.3.2. Recent cannabis use.

Recent cannabis use was assessed at the beginning of each CREMA session via “how long has it been since you last used cannabis/marijuana?” Participants could select “0-29 minutes,” “30-59 minutes,” “1-3 hours,” or “more than 3 hours ago.” For modeling purposes, this variable was dummy-coded to 0 (less than 1 hour) and 1 (more than 1 hour ago).

2.3.3. Distress tolerance.

DT was assessed at baseline using the 15-item Distress Tolerance Scale (DTS) (Simons and Gaher, 2005). Items include, “I’ll do anything to avoid feeling distressed or upset” and “When I feel distressed or upset, I must do something about it immediately.” Participants rate their agreement with a statement on a 5-point Likert-type scale ranging from 1 (Strongly Agree) to 5 (Strongly Disagree). Items are summed to create a total score where lower scores indicate low ability to tolerate distress and high scores indicate high ability to tolerate distress. Internal consistency in the current sample was 0.93.

2.3.4. Craving.

Cannabis craving was assessed at baseline using the 12-item Marijuana Craving Questionnaire Short Form (MCQ-SF; Heishman et al., 2009), consisting of four subscales: emotionality, purposefulness, compulsivity, and expectancy. Each subscale includes three items and is scored by averaging the item scores. Participants respond to each item on a Likert-type scale from 1 to 7 with anchors at 1 (Strongly disagree), 4 (Neither agree nor disagree), and 7 (Strongly agree). A score of general craving was calculated at baseline by taking the average of all 12 items. Low scores indicate low levels of craving and high scores indicate high levels of craving. Heishman et al. (2009) characterized emotionality craving as craving in anticipation of relief from negative psychological or physiological states (e.g., withdrawal). Negative affect coping-related craving was thus assessed at baseline using the Emotionality Subscale. An example item from this subscale is, “If I smoked marijuana RIGHT NOW, I would feel less tense.” Internal consistency in the current sample was 0.88 for the total scale and 0.77 for the emotionality subscale.

CREMA Sessions.

Coping-related cannabis craving was also assessed at each CREMA session before and after exposure to the image cue. Following the participants’ viewing of the image cue in a CREMA session, a modified version of the emotionality subscale was presented, e.g., “WHILE LOOKING AT THE PHOTOGRAPH, if I smoked marijuana, I would have felt less tense.” We also included a pre-cue item of general desire to use cannabis, “I have a desire to use marijuana RIGHT NOW” and a post-cue item, “WHILE LOOKING AT THE PHOTOGRAPH… I had a desire to use marijuana.” The same 7-point Likert-type scale was used for these items with low scores indicating lower craving/general desire and high scores indicating higher craving/general desire.

2.3.5. Affect.

At baseline, negative affect was assessed using the Depression, Anxiety, and Stress Scale (DASS-21; Lovibond & Lovibond, 1995). Participants respond to 21 items on a 4-point scale from 0 (Not at all true) to 3 (Extremely true). The DASS-21 consists of three subscales: Depression, Anxiety, and Stress, each including seven items which are summed to create subscale total scores. Example items include, “I couldn’t seem to experience any positive feeling at all” (depression), “I felt I was close to panic” (anxiety), and “I found it hard to wind down” (stress). Internal consistency for the full scale in the current sample was 0.93.

CREMA Sessions. Four brief questions were used to assess sadness, relaxation, frustration, and stress, e.g., “How SAD you feel now?” Participants could respond on a five point Likert-type scale with anchors at 1 (Not at all), 3 (Moderate amount), and 5 (Extremely). Following the cue, the same affect types were assessed again using, “While looking at the photograph, how ____ did you feel?” A higher score indicates a higher level of that affect. For current study purposes, we limited our analysis to sadness and relaxation because we considered them to be most closely related to feelings of distress or upset, the affect states used in items on the Distress Tolerance Scale.

2.3.6. Fidelity checks.

Two fidelity check items were also included in each CREMA session. Following the cue, participants were asked to report if they actually saw the image. Participants could respond “yes” or “no.” Participants then were asked to report how carefully they looked at the image, responding on a five point Likert-type scale with anchors at 1 (Strongly disagree), 3 (Moderately agree), and 5 (Strongly agree).

2.4. Statistical analysis

Of the 3528 possible observations (CREMA sessions), 893 (25.3%) were missing because the participant did not start or complete the CREMA session to the point at which they could view the cue. A total of 69 observations post-cue were considered missing because participants endorsed that they were unable to see the image (n = 15) and/or did not carefully look at the image (rating < 3 Moderately agree on the second fidelity check; n = 54). Baseline data for participants who completed the two-week period of CREMA sessions were assessed for outliers, as well as skewness and kurtosis. Only the Depression Subscale of the DASS-21 contained outliers (i.e., values 3.29 standard deviations away from the mean) that were corrected to one unit higher than the highest non-outlier, per recommendations of Tabachnick and Fidell (2013). No variables were power transformed. All descriptive statistics were conducted using SPSS (Statistics for Mac, Version 27.0, Released 2020; IBM Corp., Armonk, NY). Because the study enrolled participants before (n = 39) and after (n = 24) COVID-19 precautionary protocol onset, non-parametric independent samples Mann-Whitney U tests were conducted to evaluate differences in distributions of DTS, DASS-21 subscales, and MCQ-SF scores, and past month cannabis use days.

To address our hypotheses, we used a two-level random effect multilevel model in Mplus version 8.6 (Múthen & Múthen, 1998-2017) as it accommodates missing data, unequally spaced time intervals, varying numbers of observations across participants, and within-participant variance (Gibbons et al., 2010). All models were estimated using robust maximum likelihood (MLR). Four models were conducted to estimate the main effects of cue type, DT, and sex on post-cue affect (sadness, relaxation) and craving (general desire to use cannabis, coping related craving). For level one, we included cue type (0 = neutral, 1 = NA), time since last cannabis use, and within-participant mean-centered6 pre-cue affect and craving as predictors of post-cue affect and craving, respectively. For level two, we included DT, sex (0 = male, 1 = female), NA, and group-mean centered pre-cue affect and craving as predictors of post-cue affect and craving, respectively. For simplicity and to capture the broader construct, NA was operationalized as the total score of the DASS-21 (sum of all items), rather than examining each subscale individually. Finally, in 24 additional models, we examined a level 1 two-way interaction (cue type × time since last use), a level 2 two-way interaction (DT × sex), and four cross-level interactions of cue type × DT, cue type × sex, time since last use × DT, and time since last use × sex. Interactions not meeting statistical threshold (p < 0.05) were dropped per recommendations of Snijders and Bosker (2011) and in these cases, only the main effects were interpreted.

3. Results

Baseline characteristic descriptive statistics are summarized in Table 1. There were no significant differences by sex at baseline. Further, Mann-Whitney U tests indicated no significant differences in distributions of DT; coping-related craving; depressive, anxiety, or stress symptom scores; or past month cannabis use days pre- versus post-COVID-19 precautionary protocol onset. Pearson bivariate correlations showed significant associations between DT and DASS subscales, as well as with baseline coping-related craving. See Table 2.

Table 1.

Sample Demographic Characteristics by Sex

Full Sample Females Males
M (SD)/ N (%) M (SD)/ N (%) M (SD)/ N (%) t / χ2 (df)
Age 19.62 (1.04) 19.62 (0.99) 19.62 (1.12) 0.01 (61)
Race 0.91 (4)
  Black 4 (6.3%) 2 (5.9%) 2 (6.9%)
  White 54 (85.7%) 29 (85.4%) 25 (86.2%)
  More than one race 1 (1.6%) 1 (2.9%) 0 (0%)
  Unknown/not reported 2 (3.2%) 1 (2.9%) 1 (3.4%)
  Prefer not to answer 2 (3.2%) 1 (2.9%) 1 (3.4%)
Ethnicity 0.38 (1)
  Hispanic/Latino 9 (14.3%) 4 (11.8%) 5 (17.2%)
  Not Hispanic/Latino 54 (85.7%) 30 (88.2%) 24 (82.8%)
CUD Category 0.50 (3)
  No CUD (0-1) 4 (6.3%) 2 (5.9%) 2 (6.9%)
  Mild (2-3) 13 (20.6%) 8 (23.5%) 5 (17.2%)
  Moderate (4-5) 20 (31.7%) 11 (32.4%) 9 (31.0%)
  Severe (6+) 26 (41.3%) 13 (38.2%) 13 (44.8%)
Distress tolerance 51.22 (12.95) 50.06 (12.87) 52.59 (13.14) 0.77 (61)
Depressive symptomsa 3.95 (3.92) 4.24 (4.55) 3.62 (3.06) −0.62 (61)
Anxiety symptomsa 5.29 (4.43) 5.59 (4.82) 4.93 (3.98) −0.58 (61)
Stress symptomsa 6.22 (5.11) 6.41 (4.97) 6.00 (5.35) −0.32 (61)
Cannabis use days 25.11 (6.75) 25.59 (6.79) 24.55 (6.78) −0.60 (61)
General cravingb 3.41 (1.10) 3.42 (1.13) 3.40 (1.08) −0.08 (61)
Coping-related cravingc 3.17 (1.45) 3.15 (1.54) 3.20 (1.36) 0.13 (61)
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Note. Other races and ethnicities were asked of participants, however, participants in the current sample only endorsed those listed in the table. Similarly, gender identities were also asked of participants, however, all participants identified as cisgender.

a

Average scores for each subscale of the DASS-21 in the full sample and by sex were all within the “Normal” ranges (0-9 for the Depression Subscale, 0-7 for the Anxiety Subscale, 0-14 for the Stress Subscale).

b

General craving was measured using the mean of the entire MCQ at study baseline.

c

Coping-related craving was measured using the mean of the Emotionality Subscale of the MCQ at study baseline

Table 2.

Correlations Between Baseline Variables of Distress Tolerance, Negative Affect, Cannabis Craving, and Cannabis Use

DT Dep Anx Str DASS GC CRC
Distress tolerance (DT) -
Depressive Symptoms (Dep) −0.41** -
Anxiety Symptoms (Anx) −0.49** 0.65** -
Stress Symptoms (Str) −0.56** 0.65** 0.75** -
DASS total −0.55** 0.85** 0.90** 0.92** -
General craving (GC) −0.31* 0.27* 0.48** 0.38** 0.42** -
Coping-related craving (CRC) −0.43** 0.31* 0.57** 0.43** 0.49** 0.90** -
Cannabis use days −0.16 0.20 0.19 0.28* 0.25* 0.36** 0.29*
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Note.

**

p < 0.01,

*

p < 0.05.

General craving = the total scale score of the Marijuana Craving Questionnaire (MCQ). Coping-related craving = Emotionality Subscale score of the MCQ. DASS = Depression, Anxiety, Stress Scale.

Tables 3 and 4, and Figure 2, present results from the four main effects models and any retained interaction effects. NA cues consistently and significantly increased reported sadness and reduced feelings of relaxation, but had no effect on either craving assessment. More recent cannabis use (<1 hour ago) was associated with greater post-cue relaxation and coping-related craving. DT was associated with lower reported relaxation and higher reported sadness post-cue. DT was not associated with either post-cue craving assessment. Relative to male participants, females reported significantly higher sadness following exposure to NA cues. Finally, there were significant interaction effects of cue-type × sex, cue type × DT, and time since last use × sex on post-cue sadness. Female participants and those with low DT reported higher levels of post-cue sadness following NA cues compared to males and those with high DT, respectively. Female participants who last used cannabis more than one hour ago reported higher levels of post-cue sadness compared to males and those who had used within the past hour.

Table 3.

Model Results for Post Cue Affect

Model Est. (SE) p BIC
Sadness 4471.439
Within-Participant Level (n = 1554)
  Neutral vs. Negative Affective cues 1.09 (0.10) <0.001
  Pre-cue person mean-centered sadness 0.23 (0.06) <0.001
  Time since last cannabis use −0.06 (0.07) 0.38
Between-Participant Level (n = 63)
  Sex 0.27 (0.10) 0.005
  Distress tolerance −0.01 (0.004) 0.045
  Negative affect −0.004 (0.01) 0.33
  Pre-cue group mean-centered sadness 0.69 (0.09) <0.001
Cross-level Interaction Effect
  Cue type x Sex 0.54 (0.18) 0.003 4316.609
  Cue type x Distress Tolerance −0.01 (0.01) 0.04 4321.309
  Time since last cannabis use x Sex 0.29 (0.12) 0.02 4479.570
Relaxation 4451.234
Within-Participant Level (n = 1554)
  Neutral vs. Negative Affective cues −0.99 (0.11) <0.001
  Pre-cue person mean-centered relaxation 0.21 (0.04) <0.001
  Time since last cannabis use −0.18 (0.07) 0.007
Between-Participant Level (n = 63)
  Sex −0.08 (0.10) 0.43
  Distress tolerance 0.01 (0.004) 0.007
  Negative affect 0.002 (0.01) 0.68
  Pre-cue group mean-centered relaxation 0.84 (0.08) <0.001
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Note. BIC = Bayesian Information Criteria. Where BICs are listed in the far-right column indicates a separate model was conducted with that added indicator. Negative affect = average of the Depressive, Anxiety, and Stress Subscales of the DASS-21 at baseline.

Table 4.

Model Results for Post Cue Desire for Cannabis and Coping-Related Craving

Model Est. (SE) p BIC
General Desire a 3989.478
Within-Participant Level (n = 1139)
  Neutral vs. Negative Affective cues −0.25 (0.14) 0.08
  Pre-cue person mean-centered desire 0.37 (0.05) <0.001
  Time since last cannabis use −0.04 (0.07) 0.61
Between-Participant Level (n = 46)
  Sex −0.26 (0.25) 0.29
  Distress tolerance 0.02 (0.01) 0.12
  Negative affect 0.01 (0.01) 0.49
  Pre-cue group mean-centered desire 0.72 (0.08) <0.001
Coping-Related Craving 4388.061
Within-Participant Level (n = 1561)
  Neutral vs. Negative Affective cues 0.16 (0.13) 0.21
  Pre-cue person mean-centered craving 0.42 (0.06) <0.001
  Time since last cannabis use −0.12 (0.06) 0.04
Between-Participant Level (n = 63)
  Sex −0.20 (0.13) 0.11
  Distress tolerance 0.003 (0.01) 0.59
  Negative affect −0.001 (0.01) 0.86
  Pre-cue group mean-centered craving 0.86 (0.04) <0.001
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Note. BIC = Bayesian Information Criteria. Negative affect = average of the Depressive, Anxiety, and Stress Subscales of the DASS-21 at baseline. Coping-related craving = Emotionality Subscale score of the MCQ.

a

The general desire item was added later to ambulatory CREMA. As such, these analyses resulted in fewer observations.

Figure 2.

Figure 2.

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Results from Multilevel Models.

Note. Panels present results from models testing our primary hypotheses of the effect of DT and gender on post-cue affect and craving. Solid line ovals = “trait” variables measured at baseline. Solid line rectangles = “state” variables measured pre- and post-cue exposure in each CREMA session. Dotted line ovals = two-way interactions at the between-participant level. Dotted line rectangles = cross-level interactions. ** p < 0.01, * p < 0.05.

4. Discussion

To our knowledge, this is the first study to investigate the association between DT, affect, and cannabis craving in daily life, and NA cue reactivity in cannabis-using emerging adults in their natural environment using CREMA methodology (Warthen and Tiffany, 2009). Although DT was moderately to strongly negatively correlated with NA and coping-related cannabis craving at baseline, when we examined the effect of baseline DT on NA cue reactivity during the two-week CREMA period, our primary hypotheses were only partially supported.

We anticipated finding the largest effect of low DT on post-NA cue reactivity, when heightened distress may be induced. This would be in line with previous human laboratory research by Buckner et al. (2019) which demonstrated that a 3-minute distressing task with cannabis-using emerging adults induces greater distress and cannabis craving in those who reported low DT. Our study was the first to show that NA cues, presented in the context of CREMA, effectively increase sadness and decrease relaxation in frequent cannabis-using emerging adults regardless of recent cannabis use. However, although low DT was associated with lower relaxation and greater sadness post-cue, we did not find evidence that it was associated with increased cannabis craving following a NA cue. Buckner et al.’s distressing task laboratory paradigm and our brief image cue are functionally different mechanisms for inducing NA. It is possible that the brief cue presentation did not produce sufficiently high levels or the most relevant type of NA to result in coping-related craving among those with low DT. Further, the craving measures differed from Buckner et al.’s, and the coping-related craving measure may not have captured the most relevant coping-related reasons for craving cannabis. Associations between NA and cannabis use and craving have been found to be stronger among individuals with co-occuring psychiatric conditions (Buckner et al., 2016; Wycoff et al., 2018). Althouth the current study sample reported average baseline depression and anxiety scores within the sub-clinical range, recent cannabis use was predictive of greater post-cue relaxation, greater post-cue coping-related craving, and interacted with sex (females who had not used in the past hour) to predict greater post-cue sadness, suggesting that coping-related craving and motives may still be driving frequent use independent of cue exposure. Subsequent research should explore coping-related craving in response to NA cues in a sample overrecruited for co-occurring psychiatric conditions.

Previous CREMA research with adult cigarette smokers has demonstrated efficacy in inducing NA and stress following stressful cues (Tomko et al., 2020; Wray et al., 2015). Similarly, we observed greater affective reactivity, specifically sadness, to NA cues among female participants relative to males. The current study found no sex-specific effect of NA cues on cannabis craving, unlike previous research (Tomko et al., 2020), and no evidence to support a sex by DT interaction predicting craving. However, this lack of concordant evidence may be due to several study differences, including measurement and analytic procedures, sample size and charactersitics, and the pharmacological effects and frequency of use of the respective substances.

4.1. Limitations

Despite over 1500 post-cue observations, we had limited ability to examine between-participant differences and interaction effects due to our small sample size (n = 63). Further, our sample was demographically homogenous and nearly exclusively met criteria for CUD (~94% of the sample). Results may have differed with a broader range of cannabis use problem severity. Our sample was also characterized by a restricted age range (18-21) by design; this may have limited the variability in length of experience using cannabis, and NA-related use may increase as years of chronic, heavy use increase (Koob, 2015). An iOS device was required to access the CREMA app which may have excluded a large, potentially uniquely different, population. Further, CREMA sessions were not administered completely at random as participants selected the 2-hour time blocks during which CREMA sessions would be randomly prompted. However, this strategy may have facilitated participant responding, thereby minimizing missing data. Finally, CREMA session lengths were widely variable. It is possible that very short or very long session lengths could indicate random responding or inattention. However, these represented a small portion of the total sample of observations. Additionally, session duration may have shortened over the two-week period due to practice effects.

5. Conclusion

Findings support further use of CREMA methodology to better understand individual and day-to-day level processes in cue reactivity. Interestingly, no associations between affective reactivity and cannabis craving were observed in this emerging adult, largely CUD, sample. Though our results were partially inconsistent with previous laboratory research, it is not uncommon for laboratory or retrospective findings and EMA findings to be in conflict, and the source of such conflict is important to understand in subsequent research (Shiffman et al., 2015, 2008). Future work should also examine patterns of cannabis use following briefly administered NA cues. Because problematic substance use is characterized by compulsive behavior that results, at least in part, from maladaptive learning/memory processes (Hyman, 2005), the compulsive nature of use may be most effectively undermined by having a more complete understanding of acute responding to conditioned cues. CREMA-based data collection methodologies are well-positioned to advance this knowledge.

While our hypotheses regarding DT and post-cue cannabis craving were not supported, recent work suggests that addressing deficits in emotion regulation may have modest effects on cannabis use among emerging adults (e.g., Wolitzky-Taylor et al., 2022). Ultimately, continuing this line of work may inform prevention and treatment development targeting acute responding to salient affective cues in the natural environment.

Author Note:

This work was supported by National Institute of Health grants K12 HD055885 and T32 DA007288. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Kevin Gray has provided consultation to Jazz Pharmaceuticals and Rachel Tomko has provided consultation to the American Society of Addiction Medicine on topics unrelated to the investigation reported here. The other authors have no relationships to disclose.

Footnotes

1

Six people were ineligible for remote only participation at the screening stage due to not having an iOS device, though many study advertisements explicitly noted the iOS device requirement. It is likely many individuals self-selected out as a result of this requirement. Remote-only participants made up only 12.5% of the sample.

2

Participants in an oral fluid sub-study provided one oral fluid sample at orientation and then twice daily for 14 days. Otherwise, CREMA procedures were the same for these participants.

3

Regarding recent stressors, participants were asked to check any stressful situations (e.g., “had a disagreement with someone,” “received bad news”) they had experienced since their last CREMA session. Time since last cannabis use is described in the variables section below.

4

Outliers were considered to be values outside 3.29 SDs above or below the mean. There were 55 CREMA sessions lasting longer than 9 minutes and 7 seconds (or 9:07), representing 2.1% of all completed CREMA sessions. Session duration as short as 0:43 fell within the 3.29 standard deviation below the mean.

5

The upper end of this range may be the result of a glitch in the app as CREMA sessions were programmed to expire after 15 minutes. The majority (n = 2,614) of CREMA sessions were initiated in under 15 minutes. Only 74 CREMA sessions were initiated after 15 minutes.

6

For each participant, their scores on each variable across sessions/days were averaged and centered on each participant’s own mean so that our analyses could detect if a result was higher- or lower-than-average at the individual level.

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