Study of associations

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 jwditre@syr.edu 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

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(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) DI – Intolerancee 3.61 (2.77) 4.11 (2.62) 3.84 (2.9) 3.64 (3.34) 3 (2.07) 3.47 (2.81) aGeneralized Anxiety Disorder–7 item; bCenter for Epidemiological Studies Depression Scale; cGraded Chronic Pain Scale – Four-Item Interference Score; dShort- Form Health Survey–20 item; eDiscomfort Intolerance Scale.�p < .05 indicating significant omnibus test of group differences (interval data) or chi-square (count data).

78 J. D. KOSIBA ET AL.

with past-month pain severity, pain interference, and perceived discomfort intolerance and avoidance entered sep- arately in Step 2. The relative contribution of each variable entered at Step 2 to the criterion outcome of canna- bis use frequency was assessed by examining change in R- squared (DR2) and squared semipartial correlations (sr2; see Table 2).

Results

Sample characteristics

The sample was 44% male, with a mean age of 27 years (SD¼ 8.36). The mean GCPS interference score was 14.48 (SD¼ 9.60). The sample primarily reported scores in the low interference range (N¼ 69; GCPS grades I–II), yet a substan- tial portion also reported scores in the high range of pain- related interference (N¼ 40; GCPS grades III–IV). The modal frequency of cannabis use was “less than monthly” (n¼ 38), closely followed by “daily/almost daily” (n¼ 32). The modal chronic pain grade was “1/low intensity and low disability” (n¼ 38), followed by “2/high intensity and low disability” (n¼ 31), “3/high disability–moderately limiting” (n¼ 20), and “4/high disability-severely limiting” (n¼ 20). The mean CES-D score was 26.76 (range: 0–53, SD¼ 11.41), which is above the recommended cutoff for mood disorder (Henry et al. 2018). The mean GAD-7 score was 9.28 (range: 0–21, SD¼ 11.41), indicating clinically-significant anxiety symptoms (Plummer et al. 2016).

Associations between perceived DI and pain severity/ interference

Hierarchical regression analyses indicated a linear associ- ation between discomfort intolerance and pain severity (R2¼ .15; DR2¼ .04, b ¼ �0.20, t ¼ �2.21, p¼ .03; 95% CI b¼�0.13:�.01). Discomfort avoidance was not related to pain severity (p¼ .36). A linear association was also observed between the criterion variable of pain-related inter- ference and both discomfort avoidance (R2¼ .39; DR2¼ .05,

b ¼ 0.25, t¼ 2.98, p¼ .004; 95% CI b¼ 0.23:1.13) and dis- comfort intolerance (R2¼ .28; DR2¼ .03, b ¼ �0.18, t ¼ �2.17, p¼ .03; 95% CI b¼�1.22:�.06). Not shown in Table 2.

Associations between pain severity/interference, and cannabis use frequency

As hypothesized, positive linear associations were also observed between past-month pain severity and frequency of cannabis use (R2¼ .09; DR2¼ .04, p¼ .04; 95% CI b¼ 0.01:0.58), and between pain-related interference and fre- quency of cannabis use (R2¼ .09; DR2¼ .04, p¼ .04; 95% CI b¼ 0.001:0.06). Each of these pain outcomes accounted for approximately 4% of the variance in cannabis use frequency (see Table 2).

Associations between perceived DI and cannabis use frequency

Hierarchical regression analyses indicated a positive relation- ship between discomfort avoidance and cannabis use fre- quency (R2¼ .11; DR2¼ .06, p¼ .01, 95% CI b¼ 0.02:0.18), such that scores on the discomfort avoidance subscale of the perceived DI measure accounted for approximately 6% of the variance in cannabis use frequency. As seen in Table 2, the positive association between perceived discomfort intolerance and frequency of cannabis use did not reach statistical significance (p¼ .27).

Discussion

This is the first study to test cross-sectional associations between perceived DI, past-month pain severity, pain-related interference, and frequency of cannabis use. As hypothe- sized, past-month pain severity, pain-related interference, and perceived discomfort avoidance were each positively associated with frequency of cannabis use among individuals with chronic pain. Also as predicted, perceived discomfort avoidance and discomfort intolerance were both positively associated with pain-related interference. Interestingly, posi- tive associations between discomfort intolerance and canna- bis use frequency did not reach statistical significance, suggesting that aspects relevant to the subfactor of discom- fort avoidance may be of greater relevance to cannabis use frequency among individuals with chronic pain.

One potential implication of these results is that individu- als with chronic pain may be motivated to use cannabis as a means of avoiding discomfort and escaping aversive physical sensations. This interpretation is consistent with negative reinforcement model of addiction motivation (Baker et al. 2004), and is also consistent with evidence that avoidance of discomfort may exhibit a stronger association with aversive physical sensations than intolerance (Keough et al. 2011). An alternative interpretation of these results is that more fre- quent use of cannabis may contribute to increases in per- ceived DI, pain severity, and pain-related functional impairment. That is, the direction of causality in these

Table 2. Hierarchical regression models.

Criterion Variable: Cannabis Use Frequency

b sr2 t b (SE) p

Step 1 (Models 1–3) Age �0.11 �.01 �1.11 �0.02 (0.02) .42 Gender 0.00 .00 �0.04 0.01 (0.27) .85 Tobacco Use Status 0.20 .04 2.11 0.26 (0.12) .04*

Anxiety Symptomsa 0.08 .00 0.63 0.02 (.03) .53 Depression Symptomsb �0.12 �.01 �0.90 �0.01 (.02) .37

Step 2 (Model 1) Pain Severity 0.20 .04 2.03 0.30 (0.15) .04*

Step 2 (Model 2) Pain-Related Interferencec 0.22 .04 2.02 0.03 (.02) .04*

Step 2 (Model 3) DI – Avoidanced 0.25 .06 2.55 0.10 (0.04) .01**

Step 2 (Model 4) DI – Intoleranced �0.10 �.01 �1.02 �0.05 (0.05) .31

aGeneralized Anxiety Disorder – 7 item (GAD-7); bCenter for Epidemiological Studies Depression Scale (CES-D); cGraded Chronic Pain Scale – Four-Item Interference Score; dDiscomfort Intolerance Scale (DIS).�p < .05; ��p <.01.

ADDICTION RESEARCH & THEORY 79

associations remains unclear. Either way, future research examining trajectories of cannabis use frequency, discomfort intolerance, and various aspects of the chronic pain experi- ence seems warranted. In addition, it may be useful to con- sider the utility of increasing tolerance for discomfort and reducing pain to assist those who are attempting to reduce or stop cannabis use. Future research should also examine pain and discomfort intolerance in relation to cannabis- related problems (Bashford et al. 2010), cannabis withdrawal symptoms (Manning et al. 2018), cannabis use motives (Guillot et al. 2018), and barriers to cassation (Zvolensky et al. 2018).

Generalizability of these findings is limited by our recruitment of a predominantly White and well-educated sample that self-selected to participate in a study for small point-based rewards. It is also important to note that our online survey required internet access, and precluded bio- chemical verification of cannabis use. Future research should examine cannabis use among more racially diverse samples. For example, African-American cannabis users are more likely than White users to meet criteria for cannabis use dis- order (Kerridge et al. 2018). Another limitation is that although frequency of cannabis use is a clinically-meaningful outcome (Gates et al. 2016), it was measured via a self- report and on a Likert scale which may result in loss of vari- ance, and is not sufficient to characterize potentially dynamic cannabis use profiles. Future research may wish to specifically recruit for varying degrees of cannabis use. In addition, smoking topography studies indicate an imperfect association between self-reported cannabis use and puff vol- ume and duration (McClure et al. 2012), and the potency of cannabis may further modulate patterns of use (Heishman et al. 1989). Puff topography could be a useful strategy for testing or correcting for exposure to the active constituents in cannabis smoke, as users may adapt smoking behavior based on THC content (van der Pol et al. 2014).

Conclusions

Overall, the present study revealed positive associations between pain severity, pain-related interference, perceived discomfort avoidance, and cannabis use frequency among individuals reporting chronic pain. Discomfort avoidance and pain severity could be important clinical targets among individuals with chronic pain who are interested in reducing their cannabis use. Future research is needed to test patterns of cannabis use following experimental manipulation of per- ceived discomfort intolerance (Farris and Metrik, 2016), and which extends these analyses to samples of medical cannabis patients (Haug et al. 2017).

All authors contributed in a significant way to the manuscript, and all authors have read and approved the final manuscript.

Disclosure statement

None of the authors have any real or potential conflict con- flicts to declare, including financial, personal, or other

relationships with other organizations or pharmaceutical/ biomedical companies that may have inappropriately impacted or influenced the current research and interpret- ation of the findings.

Funding

This research was supported by Grant No. R01AA024844 awarded by the National Institute on Alcohol Abuse and Alcoholism to Joseph W. Ditre.

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