Authors: Julia D. Buckner
Categories: Article, anxiety, substance use disorders, motivational interviewing, alcohol, cannabis, smoking
Source: Current opinion in psychology
Authors: Julia D. Buckner
Individuals with substance misuse and substance use disorder (SUD) experience especially high rates of elevated anxiety, including anxiety disorders, and the co-occurrence of these conditions is related to worse treatment outcomes. Given that these patients may have little motivation to change their substance misuse if they use substances to cope with their chronically elevated anxiety, interventions that include components that target motivation may be especially useful. Thus, this paper reviews the recent extant literature on treatments developed specifically for these high-risk patients that include motivational interviewing (MI) techniques to increase motivation for behavioral change. Results indicate that two modalities have been tested – in-person therapies and online interventions. The majority use MI techniques to change substance use and some to change anxiety-related behaviors. The majority also incorporate cognitive-behavioral skills to manage substance use and anxiety. Data indicate that MI techniques can be administered in-person and online to decrease substance misuse and anxiety among patients with elevated anxiety and substance misuse.
People with substance use disorders (SUD) appear especially vulnerable to experiencing clinically elevated anxiety. To illustrate, nearly 50% of individuals with cannabis use disorder (CUD) meet criteria for a comorbid anxiety disorder [1]. Importantly, the co-occurrence of SUD with anxiety disorders and conditions is associated with greater impairment than either condition alone. For example, among patients presenting for treatment of CUD, anxiety was positively significantly related to more severe CUD, more cannabis-related problems, and greater cannabis use [2]. It therefore follows that these patients also have worse SUD treatment outcomes. In fact, among patients with alcohol use disorder (AUD), patients comorbid anxiety disorders are related to smaller reduction in drinking following treatment for their AUD [3]. This deleterious effect of anxiety is evident for other SUD treatment – e.g., patients with elevated baseline anxiety report more cannabis use and related problems following treatment [2]. Similarly, frequent substance use (e.g., cannabis use at least twice per week [4]) is associated with worse anxiety-related outcomes following cognitive behavioral therapy (CBT) for anxiety disorders.
Affective processing models of substance misuse [5] posit that individuals with elevated anxiety may use substances to manage their chronically elevated anxiety and thus continue to use substances despite experiencing negative substance-related outcomes due to the negative reinforcement of substance use. These patients may be less motivated to change their substance use if they rely on substances to help them cope with their anxiety. Thus, one strategy that may help these patients is motivational interviewing (MI), a client-centered, directive style for enhancing intrinsic motivation to change by exploring and resolving ambivalence regarding change [6]. Motivation enhancement therapy (MET), a brief treatment originally developed for AUD [7], combines feedback regarding the patient’s alcohol use with MI to explore and resolve ambivalence regarding change. Yet, there is little research on the efficacy of MI-based interventions for patients with comorbid anxiety disorders and SUD. Thus, the aims of this review paper are (1) describe recent MI-based interventions designed to improve outcomes for patients with co-occurring elevated anxiety and substance misuse, and (2) review the extant data on the efficacy of MI-based interventions for dually diagnosed patients.
PsychInfo was used to identify articles from 2020 to May 24, 2024 for treatment-based studies concerning anxiety and substance use (including alcohol, cannabis or marijuana, and other substances), motivational interviewing, and/or motivation enhancement therapy. Other potentially relevant studies were identified by searching the reference lists of relevant articles. Clinical trials (open trials and randomized controlled trials; RCT) using quantitative statistical methods and written in English that investigated the effects of MI-based interventions with adults for co-occurring anxiety and substance misuse were deemed eligible for the current study. The 2020–2024 timeframe was chosen to balance the small number of studies in this area with the goal of reviewing recent work in this area. Seven manuscripts concerning six interventions were located; each of these studies is reviewed below.
Four studies concerned three different in-person treatments [8–11] and three studies concerned three online interventions [12–14]. Studies concerning each of these modalities are reviewed here.
The utility of a brief motivational interviewing-based intervention (BMI) for alcohol misuse among students with symptoms of social anxiety was pilot tested with 42 undergraduates in an open trial [8]. Inclusion criteria for the study included being at least 18 years old, endorsing “at-risk” drinking the past 2 weeks, and experiencing at least moderately severe social anxiety. The BMI consisted of two sessions that used MI strategies to embody the MI spirit to elicit participant change talk, with a focus on exploring ambivalence about changing risky social drinking. Compared to baseline data, one-month follow-up data indicated that participants engaged in less heavy drinking in convivial (e.g., at a bar) settings (effect size in the medium-to-large range; but not personal-intimate settings such as before having sex) and used more protective behavior strategies (PBS; behaviors designed to mitigate risks associated with alcohol consumption; effect size in the small-to-medium range). These data indicate that MI-techniques in and of themselves, without teaching behavioral strategies to reduce drinking, may result in decreased drinking in some high-risk situations, as well as increases in the use of PBS. However, the finding that MI techniques did not result in less drinking in person-intimate settings in concerning given that that social anxiety tends to be related to greater drinking in those settings, but not in convivial ones [15]. However, given that individuals with elevated social anxiety report using less PBS which is in turn is associated with more alcohol use and related problems [16, 17], the increase in PBS use following this BMI has important implications regarding the utility of MI techniques as one avenue to ameliorate alcohol-related negative consequences among individuals with elevated social anxiety.
There have been calls for the development of personalized treatments for dually diagnosed patients that treat SUD and pathological anxiety in an integrated fashion that addresses the reciprocal nature of these disorders [e.g., 18]. One such integrated treatment was tested for comorbid social anxiety disorder (SAD) and hazardous alcohol use [9]. The integrated treatment consisted of MET-CBT for AUD [19] integrated with CBT for SAD (e.g., identify social threat cognitions, avoid social avoidance) and it was compared to MET-CBT for AUD alone. Inclusion criteria for the study included being at least 18 years of age, meting diagnostic criteria for SAD, and scoring in the hazardous drinking range on the Alcohol Use Disorders Identification Test (AUDIT) [20]. Exclusion criteria included the inability to provide locator information or participate in treatment, need for detoxification (although participants could participate once they completed detoxification), active psychosis or history of schizophrenia, current active suicidal intent, and current injection drug use or DSM-IV substance dependence (other than alcohol or tobacco). Both treatments were 10 sessions long and began with a preparatory alcohol-focused MI session followed by nine CBT sessions that integrated MI techniques to address motivation as needed. At six-month follow-up, both conditions demonstrated statistically significant reductions in SAD and AUD symptoms, and improved quality of life. The integrated treatment was associated with greater reductions in social anxiety (effect size in the medium range) and improvements in quality of life (effect size in the large range) than the alcohol-only MET-CBT (in fact, the alcohol-only MET-CBT condition remained in the clinical range at follow-up assessments, whereas the integrated condition was below clinical cut-score, on average). There was no impact of condition on alcohol outcomes. That the integrated treatment condition resulted in alcohol outcomes that were comparable to the alcohol-only MET-CBT is especially promising considering that the integrated treatment did not include more sessions of treatment. These initial findings suggest that this integrated MET-CBT for SAD and hazardous drinking may be more useful for patients with SAD than alcohol-only MET-CBT.
My team developed the first known integrated treatment for anxiety disorders and CUD, Integrated Cannabis and Anxiety Reduction Treatment (ICART), to simultaneously treat comorbid anxiety disorders and CUD in an integrated fashion [21, 22]. ICART integrates a MET-CBT for CUD [23] with a transdiagnostic CBT that addresses false safety behaviors, or behaviors that help one avoid or alleviate false threats, or anxiety-provoking stimuli [24]. The majority of individuals who use cannabis (regardless of level of anxiety) report using cannabis to cope with negative affect [25, 26] and the use of non-cannabis-related false safety behaviors is robustly related to more frequent cannabis use and use-related problems [27, 28]. However, patients with anxiety disorders may have little motivation to reduce their use of false safety behaviors if they believe that these behaviors help manage their anxiety. Thus, ICART was designed to use MI techniques to target both motivation to change cannabis use and motivation to change false safety behavior use, while teaching patients CBT skills to reduce/eliminate cannabis use as a false safety behavior as well as the use of non-cannabis-related false safety behaviors that may maintain anxiety and cannabis use, and teach CBT skills to manage other high-risk cannabis use situations (regardless of whether cannabis is used for anxiety management). ICART provides MET-based personalized feedback regarding anxiety levels and cannabis use, and encourages therapists to use MI techniques throughout the course of treatment to attend to motivation to change cannabis use and reduce/eliminate use of false safety behavior use.
A pilot RCT compared ICART to MET-CBT for CUD alone [10]. Inclusion criteria for the study included being 18–65 years old, biologically verified current cannabis use, meeting DSM-5 criteria for CUD and an anxiety disorder, and endorsing cannabis use in the past week to manage anxiety. Exclusion criteria included unable or unwilling to commit to 12 treatment sessions and assessments, no longer interested in CUD treatment, psychiatric disorder that precluded participation (e.g., psychosis), current participation in other anxiety or SUD treatment, CUD not the primary SUD, and severe active suicidal ideation. Patients in the ICART condition attended significantly more treatment sessions than those in the MET-CBT for CUD only condition (effect size I the medium-to-large range) and ICART produced decreases in cannabis-related problems (effect size in the medium range). Also, patients in the ICART condition were more likely to be abstinent post-treatment (effect size approaching medium range). Baseline severity of cannabis use and use-related problems moderated the relation between condition and post-treatment outcomes, such that among patients with greater baseline cannabis use or use-related problems, ICART was associated with less post-treatment cannabis use or problems than MET-CBT alone [11].
Given that the majority of patients with SUD do not seek treatment, including individuals with comorbid mental health disorders [29], there has been growing interest in the development and testing of online interventions to reach a wider range of treatments. One online intervention was developed to target alcohol misuse and anxiety sensitivity (AS), a transdiagnostic anxiety factor, among undergraduates with elevated AS and alcohol misuse [12]. This interactive intervention was a one-session personalized feedback intervention (PFI) that includes psychoeducation regarding AS and alcohol misuse, the BMI technique of providing personalized normative feedback (PNF) regarding the participant’s AS and drinking behaviors, and CBT skills to manage AS (e.g., interoceptive exposure exercises) and alcohol use (e.g., PBS). Inclusion criteria for the study included being at least 18 years old, college student, elevated AS, and hazardous drinking per the AUDIT. Exclusion criteria included current participation in SUD or mental health treatment. Compared to the attention control condition, the integrated PFI condition had statistically significantly greater change over the three-month follow-up period in hazardous alcohol use (although both effect sizes in the medium Cohen’s ds = 0.61 and 0.54 for PFI and control respectively), AS (effect size in the medium range for PFI and in the small-to-medium range for control), and motivation (effect size in the medium range for PFI and in the small range for control).
My team developed a similar MI-based online intervention designed specifically to target cannabis misuse and elevated negative affect, and we tested whether it would be especially useful for patients with elevated social anxiety [13]. The intervention is a PFI that integrates PNF regarding the participant’s cannabis use with behavioral strategies (e.g., relaxation training) to manage negative affect (PFI-NAC). In our initial test of PFI-NAC, undergraduates (unselected for baseline negative affect) who endorsed past-month cannabis use (reporting weekly use on average) were randomly assigned to the one-session PFI-NAC condition or an assessment-only control condition. Inclusion criteria for the study included being at least 18 years old, self-reported cannabis use in the past month, and being willing to complete the two-week follow-up survey. After statistically controlling for baseline negative affect and cannabis use frequency, baseline social anxiety interacted with condition to predict cannabis use frequency at follow-up, such that among participants with moderate or higher (but not lower) baseline social anxiety, the PFI-NAC condition was associated with less frequent cannabis use at follow-up compared to the control condition. Although effect size estimates were not reported, inspection of the unstandardized effects indicates that among participants with higher baseline social anxiety, the control condition was associated with using cannabis three days per week more frequently at follow-up than the PFI-NAC condition, compared to a difference of 0.10 days per week among participants with lower baseline social anxiety.
Similarly, researchers have attempted to target the co-occurrence of anxiety with substance misuse by testing the utility of targeting the transdiagnostic anxiety risk factor, distress intolerance, or the perceived inability to tolerate psychological distress [14]. A MI-based PFI was administered online that was designed integrated PFI for nicotine smoking cessation (including BMI strategies such as eliciting responses regarding importance/confidence/readiness to change, PNF regarding smoking behaviors, and negative consequences of smoking) with PFI material developed to target distress intolerance (e.g., PNF regarding distress intolerance, negative consequences of distress intolerance), psychoeducation about the relations of distress intolerance with smoking, and behavioral strategies to change distress intolerance. Inclusion criteria for the study included being at least 18 years old, low distress tolerance, and self-reported daily smoking of at least 5 cigarettes per day. Exclusion criteria included current SUD treatment including for smoking cessation, legal status that would interfere with participating, and not being fluent in English. Compared to PFI for smoking alone, the integrated PFI resulted in greater increase in motivation to quit smoking and intention to quit smoking (effect sizes in the medium and large ranges respectively). However, although both conditions resulted in decreases in smoking, distress intolerance, anxiety, and depression at follow-up the conditions did not statistically significantly differ on these variables (magnitude of the treatment effects were small in magnitude).
This review highlights that strides have been made in the past 3–4 years to develop and test the utility of integrated treatments for co-occurring anxiety and substance misuse that include attention to motivation. And results are promising for both in-person and remotely delivered (online) interventions. In-person treatments that appear especially promising integrate MI techniques to address motivation to change substance misuse (and in come cases to also address motivation to change anxiety related behaviors such as behavioral avoidance and the use of false safety behaviors) with CBT techniques to manage substance use and anxiety. Although some of the estimates of effect size were in the small range, even effects that are considered statically small can be clinically meaningful [30], especially in light of data indicating that patients with comorbid anxiety and SUD are at risk for not benefiting from extant interventions [2, 3].
However, this body of work is not without limitations. First, the majority of these studies use relatively short follow-up periods, ranging from post-treatment [10] or two-week follow-up [13] to six months [19]. Thus, future work with longer follow-up periods is necessary to determine whether anxiety and substance use were sufficiently treated to prevent relapse among these high-risk patients. Second, all of these treatments were developed with a focus on specific substances (alcohol, cannabis, or nicotine), yet clinical practice at many treatment facilities still relies on group therapy comprised of patients with a variety of substances. Thus, future work is necessary to test whether the promising results of interventions such as the integrated MET-CBT for AUD-SAD [9] and ICART [10] are specific to alcohol and cannabis, or whether these interventions could be used in a group setting to treat comorbid SUD and anxiety more broadly. Third, the majority of the samples used to test the utility of these interventions were non-Hispanic/Latin White and future work testing whether results generalize to more racially/ethnically diverse samples is warranted to determine whether these interventions could be culturally adapted to be more effective with patients with specific life stressors (e.g., racism) that may serve as a trigger for substance use. Despite these limitations, results from these recent papers indicate that MI techniques can be used with dually diagnosed patients and in many cases, doing so improves outcomes.