Unplanned versus planned simultaneous alcohol and marijuana use in relation to substance use and consequences: Results from a longitudinal daily study

Alcohol First, Cannabis Last: Identification of an Especially Risky Use Pattern among Individuals Who Co-Use Alcohol and Cannabis

Background: Alcohol and cannabis co-use is common and confers increased risk for potential harms, such as negative consequences and substance dependence. The existing evidence suggests that factors such as dose of delta-9-tetrahydrocannabinol (THC) consumed and order of use of each substance (i.e., using alcohol or cannabis first or last when co-using) may impact co-use outcomes. Existing co-use research has focused primarily on college-samples or young adults, and few studies have explored these nuanced relations among community samples. Methods: We examined survey data from 87 community members (mean age 32.9 years, 49.4% female) recruited from legal market cannabis dispensaries. Using a combination of regression techniques (i.e., OLS, negative binomial, censor-inflated) we modeled relations among co-use ordering patterns, THC dose and cannabis outcomes as well as interactions with sex assigned at birth and age. Results: Individuals who endorsed co-use reported significantly higher CUDIT scores than those who had never co-used (p < 0.01). Using alcohol first and cannabis last (a pattern we refer to as "AFCL") was more common among females than males (p < 0.01). In the context of typical substance use weeks, more frequently engaging in the AFCL pattern was associated with significantly higher CUDIT scores (p < 0.001) and negatively predicted positive consequences (p < 0.001). Other patterns predicted higher CUDIT scores during heavy use weeks. Conclusions: Results indicate that co-use ordering patterns are related to substance use outcomes. Further research leveraging within-subjects, longitudinal designs is needed to test causal relations between these variables.

Sex and Gender Differences in Simultaneous Alcohol and Cannabis Use: a Narrative Review

Purpose of Review

The aim is to review recent literature on sex and gender differences in patterns of use, motives, pharmacological effects, and consequences of simultaneous alcohol and cannabis use (SAC).

Recent Findings

Men engage in SAC more frequently than women. Women may have more substance-specific motives for use, while men tend to consistently endorse social/enhancement motives for both alcohol and cannabis. Regarding pharmacological effects, women experience the same subjective effects as men do at lower levels of use, with some evidence that women modulate cannabis use during simultaneous use episodes to avoid greater subjective intoxication. Finally, women appear more vulnerable to experiencing a range of positive and negative consequences from SAC relative to men.

Summary

Research has identified several important sex/gender differences in SAC and its correlates and consequences. However, research has primarily focused on white and cisgender populations, with a need for more research among racial/ethnic and gender minorities.

Daily-level simultaneous alcohol and marijuana use and its associations with alcohol use, marijuana use, and negative consequences in a young adult community sample

BACKGROUND

Simultaneous alcohol and marijuana (SAM) use has been associated with greater alcohol use and consequences at the daily level, but limited research has examined SAM use in relation to marijuana use and its consequences. This study tested daily associations between SAM use and four outcomes: alcohol use (number of drinks), marijuana use (hours high), negative alcohol consequences, and negative marijuana consequences.

METHODS

A community sample of young adults [ages 18-25, mean (SD) = 21.61 (2.17) years] with recent alcohol and SAM use was recruited (N = 409; 50.9% female; 48.2% non-Hispanic/Latinx White). Participants completed a baseline survey and six 2-week bursts of daily surveys (81.1% of morning surveys completed) and reported on substance use and negative substance-related consequences. Multilevel modeling was used to test the main aims and to explore each specific consequence.

RESULTS

Among days with any alcohol use, SAM use days were associated with consuming more drinks and experiencing more total negative alcohol-related consequences than non-SAM use days. Among days with any marijuana use, SAM use days were associated with more hours being high than non-SAM use days. Exploratory models showed that SAM use was related to five specific alcohol-related consequences and two specific marijuana-related consequences.

CONCLUSIONS

These findings build upon prior research by showing that SAM use days are linked to consuming more drinks, reporting more hours being high from marijuana, and experiencing more total alcohol-related consequences even after controlling for the number of drinks, the number of hours high, any tobacco/nicotine use, and any other substance use. SAM use was also associated with a greater likelihood of experiencing some specific consequences related to alcohol and marijuana. The findings underscore the need for additional research on SAM use and marijuana-related outcomes.

How Does Being under the Influence Affect Willingness to Experience Overlapping Effects of Alcohol and Marijuana?

OBJECTIVE

This study tested how individuals anticipate they will respond to opportunities to engage in simultaneous alcohol and marijuana (SAM) use.

METHODS

Two studies utilizing a within-subjects design were conducted. Study 1 was conducted in Spring 2021 and a replication (Study 2) was conducted in Fall 2021. Participants were presented with pairs of scenarios. One scenario pair compared how willing participants expected to be to get drunk if they were sober vs. high. Another pair compared how willing participants would be to take a hit of marijuana if they were sober vs. drunk. College attending young adults (Study 1: N = 173; female = 81%; Study 2: N = 212; female = 49.1%) with varying degrees of substance use experience were recruited.

RESULTS

In Study 1 participants reported greater willingness to get drunk when sober than when high. This was qualified by a statistically significant interaction whereby differences were greater among those who had more experience with past 30-day heavy drinking. Similar findings emerged for willingness to use marijuana. Participants anticipated greater willingness to use marijuana when sober than when drunk. This was also qualified by a statistically significant interaction whereby differences were greater among experimental or established users of marijuana than among abstainers. Study 2 findings replicated those from Study 1.

CONCLUSIONS

College attending young adults state greater willingness to remain under the influence of one substance than to engage in SAM use when opportunities arise. Simultaneous use of alcohol and marijuana among college students is likely an exception, not the rule. Implications for prevention are discussed.

Planned versus unplanned drinking and cannabis use: Do facets of trait impulsivity influence daily risk?

OBJECTIVE

Planned and unplanned substance use have been examined as predictors of heavier alcohol and cannabis use and problems at the between-person level. However, it remains unclear whether planned versus unplanned use is riskiest at the day-level, and for whom. The present study tested whether day-level planned versus unplanned alcohol and cannabis use were associated with higher alcohol and cannabis consumption and negative consequences that day and whether two impulsive traits, lack of premeditation and positive urgency, moderated associations.

METHOD

Young adults (N = 409; 50.9% female) completed five bursts of daily surveys, each consisting of a morning and afternoon report across 14 consecutive days. During a baseline session, participants reported their impulsivity (UPPS-P). During afternoon surveys, participants reported their plans to use alcohol/cannabis that night. During morning surveys, participants reported number of drinks consumed/hours spent high yesterday and negative consequences experienced.

RESULTS

Planned drinking days were associated with a greater number of drinks and negative consequences, whereas planned cannabis use days were associated with more hours spent high but not negative consequences. In the drinking quantity model, there was a significant interaction for planned versus unplanned drinking by positive urgency. Planned drinking was associated with heavier alcohol consumption across levels of positive urgency; however, unplanned drinking was associated with heavier consumption for individuals with higher (vs. lower) levels of positive urgency.

CONCLUSIONS

Day-level planned drinking and cannabis use are important factors to target in just-in-time interventions. However, interventions focused on planned and unplanned drinking may be particularly effective for individuals with higher levels of positive urgency. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

To Drink or Not to Drink: Is That the Question? Examining Correspondence and Predictive Validity of Morning Drinking Intentions for Young Adults' Drinking Behaviors and Consequences

The Theory of Planned Behavior suggests that intentions are significant and proximal determinants of behavior. The purpose of this study was to test the predictive validity of drinking intentions for subsequent same-day drinking behaviors and negative consequences. Regularly drinking young adults (N = 222, 21-29 years, 84% undergraduates) completed an ecological momentary assessment (EMA) protocol and wore an alcohol monitor for five consecutive 24-h periods spanning 6 days (Wednesday-Monday). Each morning, participants reported their drinking intentions for the day and their previous day's alcohol consumption and the number of negative drinking consequences. Multilevel models showed that, at the within-person level, on days when people reported intending to drink, to get drunk, or to drink more than usual, they had higher odds of drinking, consumed more drinks, and had higher peak transdermal alcohol concentrations later that day. However, drinking occurred on 28% of days without drinking intentions, suggesting intentions were an imperfect signal for future drinking behavior. Morning drinking intentions also predicted experiencing more negative consequences, even after controlling for alcohol consumption. On average, young adults' morning-reported drinking-related intentions predicted increased odds of same-day drinking behavior and alcohol-related consequences. However, drinking frequently occurred on days participants did not intend to drink, suggesting that focusing only on drinking intention days will result in many missed prevention opportunities. Together, these results suggest the need for additional research to increase the predictive value of drinking intention assessments and for prevention interventions aimed at helping individuals follow through on their intentions not to drink.

A qualitative examination of the decision-making process of simultaneous alcohol and cannabis use: Intentions and willingness

BACKGROUND

Alcohol and cannabis use are common among young adults and most young adults who use both substances have used them simultaneously (i.e., using both substances so their effects overlap). Because simultaneous use is associated with a greater number and severity of consequences than single substance use, research is needed to examine the decision-making process of engaging in this high-risk behavior. We conducted a qualitative examination of intentions (i.e., plans) and willingness (i.e., one's openness to engage in the behavior if an opportunity presents itself) to engage in simultaneous use from the perspective of young adults who frequently report this substance use behavior.

METHODS

We recruited 36 young adults who reported simultaneous use and heavy drinking (4+/5+ drinks for women/men; 64% women, ages 18 to 25) to participate in semi-structured interviews. All interviews were double coded for thematic analysis and both novel and a priori themes were found.

RESULTS

Young adults distinguished between intending to engage in simultaneous use and being willing to engage in simultaneous use. They reported that intentions and willingness varied from occasion to occasion. They also reported that context and alcohol consumption influenced their willingness to engage in simultaneous use. Peer pressure or offers increased their willingness to use cannabis while drinking and having current or next-day responsibilities decreased their willingness to engage in simultaneous use. Additionally, planned simultaneous use occasions were characterized as being special events where young adults consumed more substances, but were more likely to monitor their use than unplanned occasions.

CONCLUSIONS

Intentions and willingness may be important proximal predictors of simultaneous use of alcohol and cannabis. Building off this qualitative work, quantitative research should identify which factors influence the decision-making process to engage in simultaneous use and determine when intentions and willingness are most predictive of risky simultaneous use behavior.

Daily-level associations between sleep duration and next-day alcohol and cannabis craving and use in young adults

STUDY OBJECTIVES

To examine the effects of sleep duration on next-day alcohol and cannabis craving and use among young adults.

METHOD

A community sample of young adults who reported recent simultaneous alcohol and cannabis use at screening (N = 409; Mage = 21.61; 50.9% female) completed twice daily surveys (morning and afternoon) for five 14-day sampling bursts (i.e., 70 days total). Daily measurements included sleep duration, alcohol and cannabis craving, and alcohol and cannabis use (i.e., number of drinks, hours high). Multilevel models enabled examining associations between sleep duration and substance use/craving at three distinct levels: daily-level, burst-level, and person-level.

RESULTS

At the day-level, sleep duration was inversely associated with craving for both alcohol and cannabis: Stronger craving was reported on mornings and afternoons after relatively shorter sleep duration. At the burst-level, sleep duration was inversely associated with morning and afternoon alcohol craving indicating stronger alcohol craving, but not cannabis craving, during two-week periods when young adults have accumulated shorter sleep duration. Pertaining to alcohol and cannabis use, no daily-level effects were found, but the burst-level effect showed that participants engaged in greater alcohol use during two-week bursts with shorter sleep duration.

CONCLUSIONS

Based on a non-clinical sample of young adults reporting substance use, results suggest shorter sleep duration may be a modifiable risk factor as it pertains to substance use and cravings. Results highlight day-level effects of shorter sleep duration on substance use cravings and adverse effects of cumulative sleep deficit on alcohol use.

Unplanned versus planned simultaneous alcohol and cannabis use in the daily lives of a predominantly white college student sample: What are the motives, contexts, and outcomes?

OBJECTIVE

Simultaneous alcohol and cannabis use is common among college students and associated with more consumption and consequences compared to single-substance use. This study examined occasions of simultaneous use and compared planned occasions to unplanned occasions with respect to motives, contexts, consumption, and consequences.

METHOD

College student simultaneous users (N = 341; 53% women; 74% White) completed five daily surveys for 54 days. Mixed-effects models examined motives and contexts of simultaneous use occasions as a function of whether alcohol and cannabis use were (a) both planned versus (b) unplanned, no use planned, or (c) unplanned, single-substance use planned and whether alcohol and cannabis consumption and negative simultaneous use-related consequences varied across planned versus unplanned occasions.

RESULTS

Social and enhancement motives were related to planned simultaneous use; offered and coping motives were associated with planned single-substance use that became simultaneous use (vs. planned simultaneous use). Compared to unplanned use, planned simultaneous use was negatively associated with using at home or alone, and positively associated with using with others, more intoxicated people, and more people using cannabis. Planned simultaneous use was associated with more alcohol and cannabis consumption. No significant differences were found for negative consequences.

CONCLUSIONS

Planned simultaneous use was motivated by social and enhancement reasons, whereas planned single-substance use that became simultaneous use was more likely motivated by offers or for coping. Planned simultaneous use resulted in greater consumption, but not negative consequences. Results provide specific motives and contexts associated with unplanned and planned simultaneous use to be incorporated into real-time interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Within- and between-person effects of naltrexone on the subjective response to alcohol and craving: A daily diary investigation

OBJECTIVE

Naltrexone is an effective treatment for heavy drinking among young adults. Laboratory-based studies have shown that naltrexone dampens the subjective response to alcohol and craving. However, few studies have tested naltrexone's dynamic, within-person effects on subjective response and craving among young adults in natural drinking environments.

METHODS

Using daily diary data from a randomized, placebo-controlled study of naltrexone's efficacy in young adults, we examined the between-person effects of treatment condition (i.e., naltrexone vs. placebo) and medication dosage (i.e., daily, targeted, and daily + targeted) on the subjective response to alcohol and craving on drinking days. Multilevel mediation models predicted subjective response and craving from treatment condition (between-person) and medication dosage (within-person), accounting for drinking levels. All effects were disaggregated within and between persons.

RESULTS

At the between-person level, naltrexone directly blunted intense subjective effects (i.e., "impaired", "drunk") and indirectly blunted subjective effects through reduced drinking. Naltrexone was not associated with craving. Between-person effects were not significant after alpha correction, but their effect sizes (bs = 0.14 to 0.17) exceeded the smallest effect size of interest. At the within-person level, taking two (vs. 1) pills was associated with heavier drinking, and taking one (vs. 0) pill was associated with lighter drinking, and lighter drinking was associated with a lower subjective response and craving. Treatment condition did not moderate the within-person effects of dosing on outcomes.

CONCLUSIONS

Our findings suggest that the direct between-person effect of naltrexone was largest on intense subjective responses, blunting feelings of being "drunk" and "impaired". Future research using momentary (rather than daily) assessments could confirm and extend these findings.

Simultaneous Alcohol and Marijuana Use Among Young Adults: A Scoping Review of Prevalence, Patterns, Psychosocial Correlates, and Consequences

BACKGROUND

Alcohol and marijuana are commonly used by young adults, and use of both substances, particularly at the same time, is prevalent among this population. Understanding the prevalence, patterns, correlates, and consequences of simultaneous alcohol and marijuana (SAM) use is important to inform interventions. However, this literature is complicated by myriad terms used to describe SAM use, including use with overlapping effects and same-day co-use.

OBJECTIVES

This scoping review identifies and describes the peer-reviewed literature focused on SAM use by young adults and distinguishes simultaneous use from same-day co-use of alcohol and marijuana. This review also provides a narrative summary of the prevalence of SAM use, patterns of SAM and other substance use, psychosocial correlates, and consequences of SAM use.

ELIGIBILITY CRITERIA

This review is limited to papers written in English and published in peer-reviewed journals between January 2000 and August 2021. It includes papers assessing simultaneous use or same-day co-use of alcohol and marijuana among young adults ages 18 to 30. Review papers, qualitative interviews, experimental lab studies, policy work, toxicology or medical reports, and papers focused on neurological outcomes are excluded.

SOURCES OF EVIDENCE

PubMed, PsycINFO, and Web of Science databases were searched. Databases were selected and the search strategy developed in consultation with an information specialist.

CHARTING METHODS

A data charting form was utilized to specify which information would be extracted from included papers. Eight categories of data were extracted: (1) research questions and hypotheses; (2) sample characteristics; (3) study procedures; (4) definition of SAM use; (5) prevalence of SAM use; (6) patterns of SAM and other substance use; (7) psychosocial correlates of SAM use; and (8) consequences of SAM use.

RESULTS

A total of 1,282 papers were identified through initial search terms. Through double-blind title/abstract screening and full-text review, the review was narrowed to 74 papers that met review inclusion criteria. Review of these papers demonstrated that SAM use was prevalent among young adults, particularly among those who reported heavier quantities and more frequent use of alcohol and marijuana. Enhancement-related motives for use were consistently positively associated with SAM use. SAM use was associated with greater perceived positive and negative consequences of alcohol and/or marijuana use. Inconsistencies in prevalence, patterns, correlates, and consequences were found between studies, which may be due to large variations in measurement of SAM use, populations studied, methodological design (e.g., cross-sectional vs. intensive longitudinal), and the covariates included in models.

CONCLUSIONS

The literature on simultaneous use and same-day co-use of alcohol and marijuana has expanded rapidly. Of the 74 included papers (61 on SAM use; 13 on same-day co-use), 60 papers (47 on SAM use; 13 on same-day co-use) were published within the last 5 years. Future research focusing on the ways in which SAM use confers acute risk, above and beyond the risks associated with separate consumption of alcohol and marijuana, is needed for understanding potential targets for intervention.

Combined use of alcohol and cannabis: Introduction to the special issue

OBJECTIVE

Combined use of alcohol and cannabis has increased in recent years among certain age groups, and it is well established that individuals who use both alcohol and cannabis (especially if they use both at the same time) are at increased risk for substance-related harms relative to individuals who use only one substance. Far less attention has been placed on the patterns, predictors, and psychological processes associated with alcohol and cannabis co-use, which may inform prevention and intervention programming. Accordingly, this special issue was assembled to advance our understanding of the characteristics and consequences of combined use of alcohol and cannabis.

METHOD

In this introductory article, the Guest Editors present the background for this work and provide an overview of the 14 articles that comprise this special issue.

RESULTS

Studies contained in this special issue capitalize on a variety of methodologies, with a particular focus on investigating typologies of alcohol and cannabis co-use, clarifying motivational and social contexts of co-use, and tracking co-use in daily life via daily diary and ecological momentary assessment designs. Experimental and neuroimaging examinations of co-use are also included. Collectively, the studies generally provide evidence that combined use of alcohol and cannabis is associated with unique characteristics, predictors, consequences, and psychological processes relative to single-substance use.

CONCLUSIONS

The studies in this special issue provide new insight into combined use of alcohol and cannabis. They also highlight a number of promising avenues for future inquiry as the literature on alcohol and cannabis co-use continues to grow. (PsycInfo Database Record (c) 2021 APA, all rights reserved).