THE ASSOCIATION BETWEEN PERCEIVED DISTRESS TOLERANCE AND CANNABIS USE PROBLEMS, CANNABIS WITHDRAWAL SYMPTOMS, AND SELF-EFFICACY FOR QUITTING CANNABIS: THE EXPLANATORY ROLE OF PAIN-RELATED AFFECTIVE DISTRESS _______________ A Thesis Presented to The Faculty of the Department of Psychology University of Houston _______________ In Partial Fulfillment of the Requirements for the Degree of Master of Arts _______________ By Kara F. Manning August 2018 i THE ASSOCIATION BETWEEN PERCEIVED DISTRESS TOLERANCE AND CANNABIS USE PROBLEMS, CANNABIS WITHDRAWAL SYMPTOMS, AND SELF-EFFICACY FOR QUITTING CANNABIS: THE EXPLANATORY ROLE OF PAIN-RELATED AFFECTIVE DISTRESS __________________________ Kara F. Manning, B.S. APPROVED: ______________________________ Michael J. Zvolensky, Ph.D. Committee Chair Department of Psychology University of Houston ______________________________ Rheeda L. Walker, Ph.D. Department of Psychology University of Houston ______________________________ Andres G. Viana, Ph.D. Department of Psychology University of Houston ______________________________ Janice A. Blalock, Ph.D. Department of Behavioral Science University of Texas MD Anderson Cancer Center _________________________ Antonio D. Tillis, Ph.D. Dean, College of Liberal Arts and Social Sciences Department of Hispanic Studies ii THE ASSOCIATION BETWEEN PERCEIVED DISTRESS TOLERANCE AND CANNABIS USE PROBLEMS, CANNABIS WITHDRAWAL SYMPTOMS, AND SELF-EFFICACY FOR QUITTING CANNABIS: THE EXPLANATORY ROLE OF PAIN-RELATED AFFECTIVE DISTRESS _______________ An Abstract of a Thesis Presented to The Faculty of the Department of Psychology University of Houston _______________ In Partial Fulfillment of the Requirements for the Degree of Master of Arts _______________ By Kara F. Manning August 2018 iii ABSTRACT Rates of cannabis use and related problems continue to rise, ranking as the third most common substance use disorder in the United States, behind only tobacco and alcohol use. Past work suggests that perceived distress tolerance is related to several clinically significant features of cannabis use (e.g., coping-oriented use). However, there has been little exploration of the mechanisms that may underlie relations between perceived distress tolerance and cannabis use problems, withdrawal severity, and self-efficacy for quitting. The current study sought to examine the experience of pain, which frequently co-occurs with cannabis use (Ashrafioun, Bohnert, Jannausch, & Ilgen, 2015), as an underlying factor in the relation between perceived distress tolerance and cannabis related problems among 203 current cannabis-using adults (29.2% female, Mage= 37.7 years, SD= 10.2, 63% African American). Results indicated that perceived distress tolerance via pain related affective distress significantly predicted the severity of cannabis use problems (Pm= 0.60), degree of cannabis withdrawal (Pm=0.39), and lower self-efficacy for quitting cannabis (Pm=0.36). Future work may usefully explore the role of pain-related affective distress as a mechanistic factor in the context of perceived distress tolerance-cannabis relations. iv TABLE OF CONTENTS Introduction ......................................................................................................................................1 Cannabis Use in the United States ...............................................................................................1 Distress Tolerance ........................................................................................................................2 Cannabis Use and Distress Tolerance .........................................................................................3 Experience of Pain .......................................................................................................................4 Cannabis Use in Relation to Pain .................................................................................................5 A Preliminary Integrative Theoretical Model .............................................................................5 Present Study: Aim and Hypothesis ............................................................................................6 Method .............................................................................................................................................7 Participants ...................................................................................................................................7 Measures.......................................................................................................................................7 Procedure ....................................................................................................................................10 Data Analytic Plan ....................................................................................................................10 Results ............................................................................................................................................10 Descriptive Data .........................................................................................................................10 Bivariate Correlations ................................................................................................................11 Mediation models .......................................................................................................................11 Cannabis Use Problems .....................................................................................................12 Cannabis Withdrawal .........................................................................................................12 Self-Efficacy for Quitting Cannabis .................................................................................12 Discussion ......................................................................................................................................13 Tables and Figures .........................................................................................................................17 References ......................................................................................................................................25 v DISTRESS TOLERANCE, PAIN, AND CANNABIS USE PROBLEMS The Association between Perceived Distress Tolerance and Cannabis Use Problems, Cannabis Withdrawal Symptoms, and Self-Efficacy for Quitting Cannabis: The Explanatory Role of Pain-Related Affective Distress Cannabis Use in the United States Cannabis is among the most widely used substances in the United States and worldwide (Johnston, O’Malley, Bachman, & Schulenberg, 2013; United Nations Office on Drugs and Crime (UNODC), 2012), with approximately 3.8% of the world’s population reporting past year cannabis use in 2015 (United Nations Office on Drugs and Crime (UNODC), 2017). In addition, the United States has seen one of the largest increases in cannabis use in recent years, with the annual prevalence rate increasing by 34% from 2007 to 2015 among those aged 12 years and older (UNODC, 2017). With this increase, the number of daily cannabis users grew by 67% in the United States from 2007 to 2015 (UNODC, 2017). Additionally, rates of cannabis use disorder have doubled in the United Sates compared to the previous decade (Hasin et al., 2016; Hasin et al., 2015). Heavy use, and particularly use characterized by cannabis use disorder, is associated with increased risk of several negative health consequences, including respiratory problems and deficiency in cognitive functioning (Solowij et al., 2002; Volkow, Baler, Compton, & Weiss, 2014). Treatment and community studies have also examined prevalence rates of cannabis use among samples suffering from a variety of medical and psychological problems. For example, one study found that among those seeking treatment for psychosis, approximately 23% currently used cannabis, with about half of that group currently “misusing” the drug (Hambrecht & Häfner, 2000). Another community-based study found that approximately 16% of those with spinal cord injury used cannabis (Young, Rintala, Rossi, Hart, & Fuhrer, 1995), and 27% of Human Immunodeficiency Virus (HIV) positive patients used cannabis to manage symptoms (Woolridge et al., 2005). Other work has reported that cannabis use accounted for as much as 25% of the primary drug problems of individuals seeking residential drug treatment (Fligiel et al., 1997). In addition, past work suggests that cannabis can be difficult for people to stop using due to uncomfortable withdrawal symptoms including anxiety, depression, hypersomnia, and 1 DISTRESS TOLERANCE, PAIN, AND CANNABIS USE PROBLEMS weakness (Hasin et al., 2008). These studies collectively suggest that cannabis use may be overrepresented among certain “vulnerable” populations and is a primary clinical and public health concern. Distress Tolerance One stress responsivity factor of potential relevance to better understanding cannabis use is distress tolerance (Leyro, Zvolensky, & Bernstein, 2010; Zvolensky, Bernstein, & Vujanovic, 2011; Zvolensky & Otto, 2007; Zvolensky, Vujanovic, Bernstein, & Leyro, 2010). Distress tolerance reflects an individual’s perceived or behavioral capacity to withstand experiential/subjective distress related to affective, cognitive, and/or physical states (e.g., negative affect, physical discomfort; Simons & Gaher, 2005; Zvolensky et al., 2011). Distress tolerance can be measured in two different ways; perceived