Does trait mindfulness level affect quitting cannabis use? A six week follow-up study

Background: Only 29% of cannabis dependent individuals seek treatment, yet significant decreases in cannabis use are seen in 31-36% of individuals that seek treatment. Follow-up studies have found that over 60% in substance use disorders end in relapse, leading to potentially chronic and relapsing cases. New and effective therapies should be researched in order to increase the success of relapse prevention treatments. Objective: In this study we aimed to evaluate the relationship between trait mindfulness level, substance dependence severity and quitting cannabis use. Methods: A hundred and sixty four patients, diagnosed with cannabis dependence, were involved in the study; socidemographic datas were recorded and Addiction Profile Index (API), Mindfuness Attention and Awareness Scale (MAAS) were carried out. Results: We found that the trait mindfulness level is significantly related with quitting cannabis use. Discussion: Trait mindfulness may be an important determining factor of the ability to quit substance use and achieve remission. Paltun SC et al. / Arch Clin Psychiatry. 2017;44(6):139-44

can be developed by meditation practices and mindfulness-based interventions 19,23,24 .Mindfulness-based relapse prevention (MBRP) 25 , a new treatment model, has been recently developed; this model combines mindfulness meditation and cognitive-behavioral relapse prevention techniques 26 .The mindfulness practices of MBRP aim to increase an individual's awareness of external triggers and internal cognitive and affective processes; increase the ability to tolerate challenging cognitive, affective, and physical experiences 25 ; and enhance metacognitive abilities 27 .Recent studies suggest several possible mechanisms about mindfulness based interventions in addictive behaviours.Neurobiological mechanisms in areas associated with craving, negative affect, and substance use relapse may be affected by mindfulness training, altering basic neurobiological processes related to reactive behaviors.Data from clinical trials likewise suggest mindfulness training may lead to decreases in self-reported severity of factors related to relapse such as anxiety, depression, and stress, decreases in both craving and reactivity to craving and an improved ability to decouple the drinking impulse from drinking behavior 28 .Recent theories have emphasized the multi-dimensional nature of dependence and how it is influenced by positive/negative reinforcement and automaticity.Indeed, mindfulness is thought to be linked with dependence by enhancing attention control and reducing automaticity.Tiffany's cognitive processing model of addiction is an important theory that describes the relationship between mindfulness and substance use.This theory outlines how routine behaviors, including substance use, become automatic over time and thus difficult to refrain from; continued use or relapse stems from the inability to disrupt these automatic behavioral routines 29 .
The negative reinforcement model of relapse suggests that negative sensations are the most powerful motivator of chronic substance use.According to this model, individuals use substances to avoid aversive moods, such as anxiety and depression 30 .This theory intersects with the self-medication theory that suggests that individuals use substances to avoid aversive experiences and sustain positive experiences 31 .
The effect of MBRP and modified MBRP protocols in substance use disorders was evaluated in four independent research studies.MBRP treatment was reported to decrease substance use or events related with substance use, such as cravings and responses to substance triggers 27,[32][33][34][35] .Some researchers have proposed that mindfulness reduces the necessarity of avoiding aversive sensations by increasing positive sensations and reducing negative sensations [36][37][38] .Trait Mindfulness has been thought to be a naturally occurring difference among individuals or a dispositional trait 24 that can be developed through meditative practices and mindfulness-based interventions 19,23 .Individuals with high levels of trait mindfulness are theorized to be better able to view aversive experiences as being transient and to be less likely to engage in substance use behaviors as a means of coping with such experiences 20,39,40 .
Based on this information, we hypothesized that the level of trait mindfulness of individuals are positively related with their capacity to quit cannabis use and negatively related with their severity of cannabis dependence.In this study we aimed to evaluate the relationship between trait mindfulness level and cannabis use of two groups during the follow up period; group continue (GC) and group quit (GQ).In addition, we analyzed the relationship between trait mindfulness and severity of cannabis dependence in both groups.

Participants
Outpatients that were sent to our treatment center by the probation office were under probation due to illegal substance use and were involved in the study after signing an informed consent form.The patients were between 18-65 years old, could write and read and were diagnosed with cannabis dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition -Text Revision (DSM IV-TR).The study ran from 01 January 2014 to 31 March 2014 at the Department for the Treatment of Alcohol and Substance Use Disorders of Ankara Numune Education and Research Hospital.Patients with educational and language problems that prevented diagnostic psychiatric interviews, another axis-I diagnosis other than cannabis dependence, diagnosis of mental disorder due to general medical conditions, or mental retardation were excluded.The approval for the study was obtained on 18 December 2013 from the Presidential Ethics Committee of Ankara Numune Education and Research Hospital (decision number 70/2013).

Measures
After the patients signed informed consent and accepted participation in the study, sociodemographic data on patients were recorded.To measure the dependence severity, the participants were asked to fill out the Addiction Profile Index (API) developed by Kultegin Ogel, Cuneyt Evren, Figen Karadag and Defne Tamar Gurol.The API consists of the following five subscales of substance use: the characteristics of substance use, dependency diagnosis, the effects of substance use on the user, cravings, and motivation to quit using substances 41 .The API total scores are divided into three categories that describe the severity of dependence: a) < 12 points indicate low dependence, b) 12-14 points indicate moderate dependence, and c) > 14 points indicate high dependence 41 .The participants were also asked to self-asses themselves on the Mindfulness Attention and Awareness Scale (MAAS).This scale, developed by Brown and Ryan 24 , evaluates the level of mindfulness and consists of 15 items; high resulting values indicate a high level of mindfulness.The mean MAAS value of the whole sample was accepted as the determining threshold of high and low mindfulness.A validity and reliability study was conducted according to the Turkish study by Zumra Ozyesil et al. 42 .The MAAS measures only the "acting with awareness" facet of mindfulness; without "observing", "describing" and "accepting without judgement" facets.In addition to the sociodemographic data and the calculated API and MAAS scales, urine tests of cannabis metabolites were performed to evaluate cannabis use.All these tests were completed in the first meeting, after which the follow-up period began.The follow-up period consisted of 3 meetings during the six weeks after the first meeting, as one meeting every two weeks.In all meetings, urine tests were repeated.During the follow-up period, mindfulness-based interventions were not conducted with the sample.

Procedures
We followed up patients diagnosed with cannabis dependence for six weeks following diagnosis.The individuals involved in the study were further divided into two groups at the end of the follow-up period based on the results of the urine test of cannabis metabolites.During follow-up, excluding the first meeting, individuals with at least one positive urine test were included in Group Continue (GC), and individuals with negative tests were included in Group Quit (GQ).We aimed to evaluate the relationship between trait mindfulness level and cannabis use of two groups.At the beginning of the study, 190 cannabis dependent-patients were undergoing treatment at our study center, although 2 patients could not read or write, 4 patients refused to join, and 20 patients could not complete the follow-up period and were thus excluded.In total, 164 individuals were included in the study.Only male patients were included, as no female patients diagnosed with cannabis dependence visited our center during the study period.

Data analysis
We evaluated the relationship between dependence severity and trait mindfulness cross sectionally at the first meeting and followed up the patients for six weeks to assess the relationship between trait mindfulness and cannabis use by repeated urine tests.All statistical analyses were conducted with IBM SPSS for Windows, version 21.0.Numerical variables were summarized as the mean ± standard deviation; categoric variables were summarized as numbers and percentages.Parametric hypothesis tests (normality and homogeneity of variances) were performed before comparison of the groups to test if their variances were equal.To determine differences in the numerical variables of the two independent groups, a t-test was applied for parametric data.The Kruskal Wallis test was also applied; this test is used for comparing groups of two or more independent samples.The relationship between numerical variables was determined by calculating the Pearson correlation coefficients.The significance level was determined as p < 0.05.The relationship between cannabis dependence severity and trait mindfulness of two groups (GC and GQ) were analyzed by t test.The relationship between API total score and MAAS scores in the whole sample analyzed by pearson correlation coefficient.The relationship between API-subgroups and trait mindfulness in the whole sample was analyzed by kruskal wallis test.

Results
In our study, GC was composed of 79 patients who tested positive for cannabis in at least one of their urine samples (excluding the first meeting) during the 6-week follow-up period.GQ was composed of 85 patients who quit substance use during the follow-up period and thus qualified as early partial/full remission candidates; none of their urine tests (excluding the first meeting) were positive for cannabis.
The mean age of GC was 29.1 ± 8.5 and of GQ was 26.7 ± 7.0.All patients were male.No significant differences were found between two groups in regard to the sociodemographic data on age, marital status, educational level, living situation, and job status in the previous year.
Fifty-two individuals (65.8%) in GC considered cannabis to be a problem in their life in comparison with 45 individuals (52.9%) in GQ; the difference in this parameter was not statistically significant (Table 1).Fourteen individuals (17.7%) in GC had a history of legal problems related with cannabis use in comparison with 5 individuals (5.9%) in GQ; this difference was statistically significant, with a greater ratio of individuals experiencing legal problems in GC (Table 1).The relationship between level of trait mindfulness and history of using substances other than cannabis was examined for the whole sample; trait mindfulness level was significantly lower in the group that had history of using substances other than cannabis (Table 2).Statistically significant differences were found between GC and GQ in the total API scores of the subscales of substance use characteristics, dependence diagnoses, effects of substance use on the user, and cravings.These values were higher in GC than GQ (Table 3).
In addition, the MAAS score was statistically higher in GQ in comparison with GC (p < 0.001) (Table 3).
There was a negative relationship between the total API and MAAS scores for the whole sample.As the API score increased, the MAAS score decreased (p < 0.001) (Table 4).
The patients were divided into three groups based on their API scores of dependence severity: low, moderate or high.As API scores increased from low to high, the MAAS score demonstrated a corresponding decrease (Table 5).Upon comparing the API groups given their total MAAS scores, significant differences were found between API groups of low and high severity (p < 0.001) and between the groups of moderate and high severity (p < 0.05), although no significant difference was found between the groups of low and moderate severity.

Discussion
To our knowledge, this is the first study in literature to evaluate the relationship between the level of trait mindfulness, severity of cannabis dependence and capacity to quit cannabis use.During the follow-up period of our study, we found that the level of trait mindfulness was significantly higher in GQ, or those that quit cannabis use, in comparison with GC, composed of individuals that tested positive for cannabis in at least one drug test.This result is consistent with other research studies that have reported that higher levels of mindfulness are negatively related with substance use frequency 43,44 .All individuals are born with the capacity to exercise mindfulness, although they may possess varying levels of the trait.Trait mindfulness may be an important determining factor of the ability to quit substance use and achieve remission.Furthermore, when we compared the relationship between level of trait mindfulness and history of use of substances other than cannabis across the whole sample, trait mindfulness was significantly lower in the group with history of using substances other than cannabis.Mixed substance abuse can result in serious problems, such as suicide 45 .
Mindfulness-based interventions are reported to reduce alcohol and other substance use/abuse cases 14 .We found a statistically significant relationship between trait mindfulness and dependence severity.In the whole sample, as the mindfulness level lowered, the severity of dependence level increased.Similar with our data, Vidrine et al. 46 reported higher mindfulness levels in nicotine-dependent individuals with lower dependence severities.Other studies have reported that individuals with high dependence severity have more problems in social, work and family life 47,48 , and more intensive treatment and support are needed in these cases 49 .This evidences that increasing mindfulness may correlate with decreasing dependence severity and other problems caused by substance dependence.In the other hand high dependence severity level is related with severe chronic substance use; the level of mindfulness might have been decreased as substance use might negatively influence attention and awareness.We divided our sample into three groups according to dependence severity as scored by the API: low, moderate, and high.As API scores increased from low to high, MAAS scores significantly decreased.There were significant differences between API groups of low and high severity (p < 0.001) and between groups of moderate and high severity (p < 0.05); however, no significant difference was found between groups of low and moderate severity.This may be indicating that individuals with low and moderate dependence could benefit from similar interventions, yet highly dependent individuals may need more intensive interventions.Additional complications and loss of functionality are observed in individuals with high levels of dependence, and treating this group is more difficult.Increasing levels of mindfulness may be an important, effective and new treatment model for individuals with high dependence in order to encourage abstinence and reduce the severity of substance dependence.We found that the API scores considering substance use characteristics, dependence diagnosis, effects of substance use on the user, and cravings were statistically significantly lower for GQ than GC.Furthermore, the prevalence of substance abuse and associated life problems, history of legal problems, level of substance dependence, and effects of substance use on the user were all lower in GQ in comparison with GC; these results are consistent with the nature of dependence.Cravings is another parameter that results in incompliance with treatment and relapse during treatment of substance dependence [50][51][52] .In our study, cravings were higher in GC than GQ.These findings were consistent with the studies of Bowen  et al. (2009) and Vidrine et al. (2009) that focused on the relationship between different aspects of mindfulness and substance use.The severity of cravings may be decreased by increasing an individual's level of mindfulness.This finding may imply that mindfulness-based treatments could be proposed as new and effective treatment models for cannabis dependence.
It seems to be a paradox that the ratio of individuals that consider cannabis use to be a problem is not statistically significantly different between in GC and GQ, even though the level of mindfulness of GC was significantly lower than GQ.GC also reported a statistically higher history of legal problems, which could be explaining this result.

Limitations
In the study period, no female individuals with cannabis dependence were involved, so the relationship between gender and level of mindfulness could not be evaluated.The API scale was a selfreported scale, and this may be one limitation of our study.MAAS was the only scale used to measure mindfulness in our study, based on a Turkish validity and reliability search.MAAS measures acting with awareness, only one component of mindfulness, so this may be another limitation.The data in our study were collected crosssectionally, yet whether or not mindfulness-based treatment methods could improve mindfulness levels or provide benefits in cannabisdependent patients is unable to be directly determined.

Recommendations
As we determined the negative relation between trait mindfulness level and cannabis use behavior, this may encourage the expansion of mindfulness based interventions in cannabis dependence.Also longterm follow-up studies are needed to evaluate if chronic substance use decrease mindfulness levels of individuals.In addition further cross-sectional and follow up studies are needed in substance use disorders other than cannabis which evaluate the effect of trait mindfulness on treatment results.

Figure 1 .
Figure 1.Flow diagram of the study.

Table 1 .
Comparison of group continue and group quit due to having history of legal problems depending on cannabis use and thinking cannabis use is a problem

Table 2 .
The relationship between MAAS score and history of substance use other than cannabis ın whole sample MAAS: Mindfulness Attention Awareness Scale.*: p value obtained by applying t test.Ave: average; SD: standard deviation.

Table 4 .
API total score and MAAS total score relationship ın the whole sample

Table 5 .
The Relationship Between API-subgroups and Mindfulness

Table 3 .
Comparison of API subscales' values.API total values.MAAS total values between the groups API: Addiction Profile Index; MAAS: Mindfulness Attention Awareness Scale.*: p value obtained by applying t test.Ave: average; SD: standard deviation.