Elsevier

Drug and Alcohol Dependence

Volume 159, 1 February 2016, Pages 219-226
Drug and Alcohol Dependence

Full length article
Marijuana dependence moderates the effect of posttraumatic stress disorder on trauma cue reactivity in substance dependent patients

https://doi.org/10.1016/j.drugalcdep.2015.12.014Get rights and content

Highlights

  • Examined moderating role of marijuana dependence on trauma cue reactivity in post traumatic stress disorder (PTSD).

  • In absence of marijuana dependence, PTSD patients had more subjective reactivity.

  • No differences in reactivity for marijuana dependent patients as a function of PTSD.

  • Marijuana dependent PTSD patients less reactive than PTSD-no marijuana patients.

  • Marijuana dependence may lead to a dampening of reactivity in patients with PTSD.

Abstract

Background

Individuals with posttraumatic stress disorder (PTSD) are at heightened risk for marijuana use. Although extant studies speak to the importance of examining the co-occurrence of PTSD and marijuana use as it relates to a variety of clinically-relevant outcomes, no studies have explored the way in which marijuana use may affect in-the-moment emotional responding among individuals with PTSD. Thus, the purpose of this study was to explore the role of marijuana dependence in the relation between PTSD and subjective and biological emotional reactivity in response to a trauma cue.

Methods

Participants were 202 patients with and without current PTSD consecutively admitted to a residential SUD treatment facility. Patients were administered diagnostic interviews, and subjective (negative affect) and biological (cortisol) reactivity to a personalized trauma cue were assessed.

Results

Whereas current PTSD was associated with greater subjective emotional reactivity among participants without marijuana dependence, there were no significant differences in subjective emotional reactivity as a function of PTSD status among participants with marijuana dependence. Moreover, marijuana dependent participants (with and without PTSD) reported less subjective emotional reactivity than participants with PTSD and without marijuana dependence. No significant findings were obtained for cortisol reactivity.

Conclusions

Findings suggest that patients with co-occurring PTSD and marijuana dependence may experience alterations in their emotional processing in response to a trauma cue (i.e., dampening of arousal). Additional research is required to clarify the specific mechanisms through which marijuana use influences emotional reactivity and fear-related emotional processing, as well as how such effects may influence PTSD treatment.

Introduction

Posttraumatic stress disorder (PTSD) is characterized by the presence of re-experiencing, avoidance, and hyperarousal symptoms, as well as negative alterations in cognition and mood, following exposure to a traumatic event (American Psychiatric Association [APA], 2013). The symptoms of PTSD have the potential to result in broad functional impairment (Rodriguez et al., 2012) and contribute to the development of other psychiatric disorders (Kessler et al., 1995), especially substance use disorders (SUD; Chilcoat and Menard, 2003). Within the extant literature, the majority of studies examining the co-occurrence of PTSD and SUD have focused on alcohol or cocaine use disorders (e.g., Coffey et al., 2007, Jakupcak et al., 2010, Waldrop et al., 2007); however, there is an emerging body of literature exploring the connection between PTSD and marijuana use.

Research has shown that individuals with PTSD are at heightened risk for marijuana use. For example, in the National Comorbidity Survey, current PTSD was found to be uniquely associated with increased rates of past year marijuana use and daily marijuana use (Cougle et al., 2011). Likewise, PTSD symptom severity demonstrates a significant positive association with frequency of marijuana use (Bonn-Miller et al., 2011a, Bremner et al., 1996). Notably, the relation between PTSD and marijuana use is also clinically-relevant. Within a sample of military veterans with PTSD, Bonn-Miller et al. (2013) found that a pretreatment diagnosis of a marijuana use disorder was associated with weaker response to residential PTSD treatment even when other relevant factors (e.g., trauma severity) were considered. Similarly, PTSD symptom severity is positively associated with using marijuana to cope, marijuana use problems, and severity of marijuana withdrawal symptoms (Boden et al., 2013, Bonn-Miller et al., 2011b, Bonn-Miller et al., 2007, Earleywine and Bolles, 2014). Although these studies highlight the importance of examining the co-occurrence of PTSD and marijuana use as it relates to a variety of clinically-relevant outcomes, no studies to date have explored the way in which marijuana use may affect in-the-moment emotional responding among individuals with PTSD.

There is reason to believe that the presence of marijuana use could influence emotional responding to trauma cues among individuals with PTSD; however, the precise way in which emotional responding would be affected is unclear. For example, it is possible that individuals with PTSD may exhibit more intense emotional responses to a trauma cue in the context of marijuana use—consistent with findings that marijuana users report greater emotion dysregulation than non-users (Bonn-Miller et al., 2008). Thus, it is possible that marijuana use may further exacerbate the heightened emotion dysregulation found in PTSD (Tull et al., 2007), contributing to greater trauma cue emotional reactivity within this population. Moreover, findings that individuals with marijuana dependence exhibit greater subjective reactivity to a biological challenge (CO2 inhalation) than those with marijuana abuse (Bonn-Miller and Zvolensky, 2009) suggest that there may be a dose-response relationship with regard to the level of marijuana use and emotional reactivity.

Alternatively, an emerging body of research on the effects of marijuana use on emotional responding suggests that marijuana use may dampen emotional reactivity in response to a trauma cue among individuals with PTSD. The amygdala (an area of the brain implicated in the development and maintenance of pathological anxiety and PTSD; Liberzon and Sripada, 2007) includes a high density of CB1 cannabinoid receptors (Perra et al., 2008), activation of which diminishes anxiety responses and amygdala activation in response to aversive stimuli (Patel et al., 2005). Consequently, ingestion of Δ9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in marijuana and a selective CB1 agonist, may correspond with attenuated threat-related emotional reactivity among individuals with PTSD. In support of this notion, studies have demonstrated that marijuana use is associated with reduced amygdala reactivity among individuals with comorbid marijuana dependence and major depression (Cornelius et al., 2010). Likewise, administration of THC in healthy recreational marijuana users (i.e., marijuana users who do not meet criteria for a marijuana use disorder) significantly reduced amygdala reactivity in response to threat signals (Phan et al., 2008). Moreover, Van Leeuwen et al. (2011) found that repeated marijuana users exhibit lower stress reactivity levels (as indexed by cortisol levels) than individuals who have never used tobacco or marijuana in their lifetime. Finally, individuals with marijuana dependence have been found to exhibit a reduced subjective and biological sensitivity to negative emotion cues (i.e., unpleasant pictures), relative to abstinent marijuana users and healthy controls (Somaini et al., 2012).

The purpose of the current investigation was to explore the role of marijuana dependence in the relation between PTSD and subjective and biological emotional reactivity in response to personalized trauma cues. This investigation was carried out in a sample of substance dependent patients in residential SUD treatment—a clinical population at high-risk for both PTSD and marijuana dependence (Chen et al., 2011). Given the absence of research in this area, as well as conflicting evidence with regard to the particular impact of marijuana dependence on emotional responding in PTSD, no specific hypotheses were made.

Section snippets

Participants

Participants for the current study included 202 patients (100 women) from a SUD inpatient treatment facility who reported exposure to at least one potentially traumatic event. Participants ranged from 18 to 60 years of age (Mean = 34.32, SD = 10.10) and were ethnically diverse (60.4% White; 36.6% African American; 1.5% Latina/o). With regard to educational attainment, 34.1% of participants reported receiving their high school diploma or GED and an additional 38.1% reported completing some form of

Preliminary analyses

Of the study sample, 26.7% (n = 54) met criteria for current PTSD and 29.2% (n = 59) met criteria for current marijuana dependence. Data on the distribution of participants across the different groups are presented in Table 2. Pre- and post-script descriptive data for subjective emotional reactivity and cortisol reactivity as a function of PTSD and marijuana dependence status are presented in Table 3. There was no significant difference in rates of marijuana dependence between participants with

Discussion

The goal of this study was to examine the moderating role of marijuana dependence on the relation between PTSD and subjective and biologically-indexed emotional reactivity to a personalized trauma cue. Results revealed that current PTSD was associated with greater subjective emotional reactivity to the trauma script only among participants without marijuana dependence; among those with marijuana dependence, subjective emotional reactivity did not differ as a function of PTSD status. Moreover,

Conflict of interest

No conflicts declared.

Funding

The funding source (the National Institute on Drug Abuse of the National Institutes of Health) had no involvement in this study.

Contributors

Drs. Tull and Gratz oversaw the study from which these data came. All authors were equally involved in study conceptualization, data analysis, and the writing of this manuscript.

Acknowledgements

This study was funded in part by R21 DA030587, awarded to Dr. Tull from the National Institute on Drug Abuse of the National Institutes of Health. The authors would like to thank the Mississippi State Hospital Chemical Dependence Units and the Bureau of Alcohol and Drug Services of the Mississippi State Department of Mental Health for their assistance with this study.

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