Addressing Alcohol or Cannabis Use in Patients With Anxiety Disorders

CATEGORY 1 CME

Premiere Date: August 20, 2024

Expiration Date: February 20, 2026

This activity offers CE credits for:

1. Physicians (CME)

2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

To engage readers in an introductory review of the common issues pertaining to comorbid anxiety disorders and alcohol and cannabis use so that they gain insights into effective screening strategies and intervention approaches.

LEARNING OBJECTIVES

Learn to assess the impact of alcohol and cannabis use on anxiety treatment outcomes, recognizing potential adverse effects and interactions.

Learn about evidence-based behavioral interventions, including cognitive behavioral therapy and motivational interviewing, tailored to address co-occurring anxiety and alcohol/cannabis use.

TARGET AUDIENCE

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource,® LLC, and Psychiatric Times.® Physicians’ Education Resource, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.

OFF-LABEL DISCLOSURE/DISCLAIMER

This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource, LLC.

FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION

The authors report that they were supported by grants from the National Institute on Alcohol Abuse and Alcoholism (K24AA025703), the National Institute of Mental Health (K23MH126078), and the National Institute on Drug Abuse (T32DA007250). Otherwise, none of the staff of Physicians’ Education Resource, LLC, or Psychiatric Times or the planners or the authors of this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

For content-related questions, email us at PTEditor@mmhgroup.com; for questions concerning the accreditation of this CME activity or how to claim credit, please contact info@gotoper.com and include "Addressing Alcohol or Cannabis Use in Patients With Anxiety Disorders" in the subject line.

HOW TO CLAIM CREDIT

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Many individuals with anxiety disorders use alcohol or cannabis for temporary relief of worry, sleeplessness, tension, and other typical anxiety symptoms. For some, this coping response can lead to worsening anxiety and impairment over time.^1,2 Common anxiety disorders and related conditions such as generalized anxiety, panic, social anxiety, and posttraumatic stress disorder (PTSD) also are correlated with the development of substance use problems.^3,4

Prevalence estimates suggest that 15% to 20% of individuals with anxiety have a substance use disorder (SUD),^5,6 with alcohol and marijuana being the most commonly used substances.⁷ Nearly 1 in 5 individuals with anxiety report using alcohol to cope with symptoms.⁸ Adults with anxiety are 2 to 3 times more likely to use cannabis compared with the general population, with rates increasing post legalization.⁹

The following is a review of how the use of alcohol and cannabis may complicate anxiety treatment. Given the widespread consumption of alcohol and cannabis, the review will include some ways clinicians can recognize and treat problematic levels of use. Many patients with both anxiety and substance use problems seek treatment in mental health rather than addiction treatment settings, highlighting the importance of psychiatric clinicians in addressing these co-occurring conditions.¹⁰

SUDs and Anxiety Disorders

SUDs are characterized by difficulty controlling use despite serious consequences for one’s life or health. In DSM-5-TR, SUDs are categorized as mild, moderate, or severe.^11,12 Risky alcohol or cannabis use that falls short of a SUD can still complicate a patient’s anxiety treatment, although consumption parameters describing risky use are better defined for alcohol.

The current recommended alcohol use limits from the National Institutes of Health are 1 drink per day (or 7 per week) for women and 2 drinks per day (or 14 per week) for men.¹³ Patients with anxiety disorders may be better off drinking even less. Older adults and those with comorbidities such as diabetes and high blood pressure have increased vulnerability.

In addition to worsening anxiety symptoms, alcohol use—even at low levels—has the potential to reduce the effectiveness of anxiety disorder treatment through adverse medication interactions or interference with exposure-based behavioral interventions.^14-16

Cannabis continues to become more accessible and socially accepted due to increasing state-level legalization,¹⁷ which currently includes 24 states and the District of Columbia. Results of a recent survey indicate that individuals consider daily cannabis use and secondhand smoke safer than tobacco smoke.¹⁸ In contrast with alcohol, thresholds that mark unhealthy cannabis use can be difficult to define, especially given the variety of cannabis modes of use, strains, and potency levels.

Initial research suggests that although cannabis use (ie, less than once a month) is not associated with anxiety treatment outcomes,¹⁹ heavier cannabis use (ie, 2 or more times per week) is associated with poorer outcomes.²⁰ Some patients may see their cannabis use as helpful in reducing anxiety—a view that is supported by results from limited retrospective studies.²¹ Nevertheless, although cannabis and other substance use may indeed provide short-term relief from anxious symptoms, it is important to note that reliance on substances to calm anxiety may limit opportunities for patients to learn more adaptive strategies to manage anxiety, such as emotion regulation skills.

Psychiatric clinicians should discuss these complex issues around cannabis use with patients in an open manner. This includes acknowledging potential benefits experienced by patients while assessing and educating patients about aspects of use that may conflict with patients’ anxiety management goals.

For example, while dosing considerations for cannabis depend on several factors (eg, mode of use or product strength),²² key information to share with patients includes findings that higher doses (12.5 mg) of tetrahydrocannabinol (THC), a psychoactive ingredient in cannabis, can be associated with increased anxiety²³ and that the average THC content in cannabis products has increased over the past 2 decades.²⁴

Anxiety disorders are associated with both cannabis use ( OR, 1.24) and cannabis use disorder (1.68),²⁵ with greater frequency of cannabis use associated with greater odds of psychosis (risk ratio: 1.10 for monthly use, 1.35 for weekly use, 1.76 for daily use),²⁶ and past-year use demonstrating greater odds of panic disorder compared with individuals who did not use cannabis in the past year (unadjusted OR, 1.2-2.3). In addition, ingesting large amounts of cannabis can induce anxiety. Risk factors for anxiety induction by cannabis intoxication are listed in Table 1.^19,27

Screening and Assessment

Many relatively brief screening instruments are available and well-validated to identify problems with alcohol, cannabis, and other commonly used substances, such as the patient-reported (and easily administered) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).^28,29 ASSIST consists of 8 questions covering tobacco, alcohol, cannabis, and other drugs. A risk score (low, moderate, or high) is provided and can be used to consider intervention level (eg, brief advice to reduce use or a more extensive approach). The Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool is a similar instrument designed to be self-administered on a computer in health care settings.³⁰ It also yields risk scores.

For both alcohol and cannabis, clinicians should ask patients about quantity and frequency of use, symptoms of cannabis or alcohol use disorder, and any other problems they may have encountered. It is also useful to explore beliefs about anxiety-related effects or benefits and other motivations for alcohol or cannabis use. Other helpful details from the patient would include drinking frequency above recommended limits⁸ and the extent to which the patient uses alcohol to manage anxiety symptoms.

When assessing cannabis use, some additional relevant considerations include the extent of daily use and age of first use, given that more frequent use and use at younger ages (eg, during adolescence) are consistently associated with worse mental health outcomes compared with occasional use and older age of starting to use.³¹ The clinical interview can also assess quantity of use and THC potency based on patients’ perceptions or the information they obtain from product labels.³²

Intervention Strategies

Clinicians can use several evidence-based approaches to help patients with anxiety reduce problematic alcohol and cannabis use. Behavioral intervention strategies such as cognitive behavioral therapy (CBT) and mindfulness training can be applied to both anxiety symptoms and substance use, and they can be effective in teaching patients new coping skills. Meta-analyses of intervention studies have indicated that CBT for SUD has a moderate to large effect size, indicating strong evidence for efficacy (eg, d = .45; g = .80),^33,34 whereas mindfulness-based interventions, such as mindfulness-based relapse preventions, have small to medium effects (eg, d = .37-.58).^35,36

Pharmacological treatments are more established for alcohol use than they are for cannabis, but new compounds are actively being tested. Recommended dosages are titrated based on a variety of patient factors and should be determined on a case-by-case basis. General guidelines can be found in Table 2.^5,37-39

Lastly, promising digital therapies such as mobile apps can help patients manage anxiety and track and reduce substance use over time. A systematic review indicates a range of effect sizes and evidence quality regarding the efficacy of apps for substance use (d = .17-.70).⁴⁰ Thus, we recommend using apps that have strong quality of evidence and have undergone more rigorous testing, such as those described in Table 3.^41,42

For patients willing to engage in structured behavioral interventions (Table 4), CBT is a helpful treatment approach for either cannabis or alcohol use problems.^43,44 Principles of CBT such as learning new behavioral and thought patterns, tracking behaviors, and managing avoidance are relevant to both anxiety and substance use treatment. Typical CBT protocols for SUD range from 8 to 14 sessions. Sessions focus on increasing awareness of antecedents and consequences of substance use and leveraging behavior-change principles to reduce or eliminate substance use through environmental and social reinforcement.

Throughout treatment, individuals learn about processes that underlie substance use, with an emphasis on understanding the thoughts and behaviors associated with their substance use, and gain skills to modify unwanted behaviors. In doing so, individuals become better equipped to identify and cope with triggers, challenge thoughts that precipitate use, manage high-risk situations, and reinforce behaviors that align with their recovery goals. Patients can be guided to understand how substance use may worsen anxiety and how to find room for alternative coping behaviors (eg, pleasant activities, mindfulness meditation).^45,46 Many manualized CBT interventions address both substance use and anxiety disorders.^47,48

Motivational interviewing (MI) is another key strategy for addressing cannabis use and unhealthy drinking that can be integrated into mental health care settings.^11,49 MI is a patient-centered collaborative style of communication useful for strengthening motivation and commitment to change.⁵⁰ Using MI, clinicians can help evoke reasons for change, resolve ambivalence, and move to action around reducing alcohol and cannabis use. Open-ended questions can help clinicians explore patients’ ambivalence related to reducing substance use and reinforce self-efficacy and “change talk” associated with anxiety coping that does not involve substances.

Mindfulness-based relapse prevention also may be valuable in reducing substance use and building skills to manage anxiety.⁵¹ Common across mindfulness-based and exposure-based therapies is a focus on building interoceptive awareness—eg, awareness of one’s body signals—and observing them without judgment instead of avoiding them or fearing them. For example, patients may be advised to practice mindfulness when experiencing substance cravings and to increase present-moment awareness.

Medications to help reduce alcohol use can be useful (Table 2), especially in conjunction with CBT,^5,37-39 although medication development for cannabis has been less successful.³⁹ Selective serotonin reuptake inhibitors (SSRIs) can help with comorbid anxiety and alcohol use problems. Gabapentin has demonstrated positive effects on alcohol treatment outcomes, mood symptoms, and sleep.⁵²

Topiramate can reduce the frequency of alcohol use and cravings as well as PTSD symptom severity.⁵³ Naltrexone and disulfiram have been effective in treating patients with PTSD and alcohol use disorder, showing a reduction in alcohol use and symptoms of PTSD.⁵⁴ Naltrexone is often the first choice to specifically address alcohol use cravings, and at least 3 to 4 months is a reasonable trial period.⁵⁵

Clinicians should be mindful of specific potential interactions between medications (eg, psychiatric medications and disulfiram).⁵⁶ However, alcohol use medications generally are well tolerated and can potentially be used in combination with medication for anxiety (eg, as in prior research on naltrexone and sertraline).⁵⁷

Despite the testing of new compounds,⁵⁸ there are no currently approved medications for the management of cannabis use disorder.⁵⁹ This gap makes the use of behavioral interventions particularly important for the comorbidity of cannabis and anxiety. Some work suggests that active cannabis use can counteract the efficacy of SSRIs and increase the risk of adverse effects. Cannabis affects how the liver breaks down these medications, leading to higher doses in the bloodstream.⁶⁰

Several mobile apps to reduce anxiety are available,³⁸ and others focused on alcohol and cannabis use are in different stages of testing (Table 3).^39,41,42 The small number of established apps to help treat SUD includes reSET and reSET-O,⁶¹ which use cognitive behavioral and contingency management principles to target substance use generally (reSET) as well as opioid use disorder specifically (reSET-O). These apps are cleared by the US Food and Drug Administration as SUD digital therapeutics and are available to prescribe for insurance reimbursement.

The Step Away app is focused on reducing unhealthy alcohol use (whether through moderation or abstinence) and is based on principles of motivational enhancement, relapse prevention, and community reinforcement.⁶² These emerging tools may be especially helpful for patients without access to other forms of treatment.

Concluding Thoughts

Cannabis and alcohol use are often associated with anxiety, and these combined problems may be challenging to manage. Screening in psychiatry is essential because patients are more likely to seek mental health care than they are to seek addiction treatment. Although there is a need for additional intervention development, behavioral strategies such as MI and CBT can reduce alcohol and cannabis use in those with anxiety. Medications to help reduce unhealthy alcohol use are well established and should be more widely offered in mental health settings, whereas medications to reduce cannabis use have yet to show efficacy.

Despite wide availability, the generally unregulated status of apps⁶³ has prompted new approaches to understanding available products. Guidelines from professional organizations such as the American Psychiatric Association can be useful in staying up-to-date on new mobile app developments^64-66 and informing patients and clinicians about emerging treatment options.

Dr Satre is a professor in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco, and an adjunct investigator in the Division of Research at Kaiser Permanente Northern California. Drs Mian and Van Doren are postdoctoral fellows in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco, and in the Division of Research at Kaiser Permanente Northern California. Dr Iturralde is a research scientist in the Division of Research at Kaiser Permanente Northern California.

Disclosure: The authors were supported by grants from the National Institute on Alcohol Abuse and Alcoholism (K24AA025703), the National Institute of Mental Health (K23MH126078), and the National Institute on Drug Abuse (T32DA007250).

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