Understanding the complex dynamics of substance use behaviors remains a significant challenge in mental health research. A new study published recently in the International Journal of Mental Health and Addiction sheds light on the nuanced interactions between psychological inflexibility, distress tolerance, cigarette dependence, and binge drinking among individuals who also use cannabis for therapeutic purposes. This research not only expands upon existing frameworks of addiction psychology but also offers critical insights that could inform tailored interventions for a unique subset of substance users.
Psychological inflexibility, a core concept in acceptance and commitment therapy, refers to rigid patterns of thinking and behavior that limit an individual’s ability to adapt to changing emotional or situational contexts. It has been increasingly recognized as a transdiagnostic factor perpetuating maladaptive coping strategies across a range of mental health disorders. In the context of substance dependence, psychological inflexibility may exacerbate compulsive use, making recovery more challenging. This study explores how this rigidity interacts with distress tolerance — which defines how individuals endure and respond to negative emotional states — in influencing cigarette dependence and binge drinking behaviors.
The researchers focused specifically on people who use cannabis therapeutically, a population that has grown in numbers with expanding legalization and acceptance worldwide. Therapeutic cannabis users often have histories of substance use, yet their co-use patterns with other substances, particularly alcohol and tobacco, remain poorly understood. This study’s premise was to clarify how psychological variables contribute to dependence on cigarettes and episodic heavy drinking among these therapeutic cannabis consumers, who represent a clinically relevant and demographically distinct group.
To achieve this, the authors employed sophisticated psychometric tools to measure psychological inflexibility and distress tolerance. These were then correlated with self-reported levels of cigarette dependence and binge drinking frequency. The study design facilitated the delineation of independent and interactive effects of these psychological constructs, providing a granular view of how internal psychological states may drive external substance-related behaviors. This methodology allowed for a nuanced appreciation of the multifaceted nature of co-use and reliance on multiple substances.
One of the pivotal findings was that psychological inflexibility showed a robust positive association with cigarette dependence, underscoring that individuals with rigid psychological profiles may rely heavily on nicotine as a maladaptive coping mechanism. This dependence appeared to be further exacerbated in those with low distress tolerance, highlighting a double bind where a reduced capacity to withstand discomfort fuels the compulsive use of cigarettes. This interplay signals that interventions to increase psychological flexibility and distress tolerance might be particularly beneficial for reducing tobacco reliance.
The relationship between binge drinking and the psychological variables was equally revealing. Binge drinking, characterized by episodic heavy alcohol consumption, was significantly associated with psychological inflexibility. However, distress tolerance did not emerge as a strong standalone predictor for binge drinking, suggesting that while rigid thinking patterns may predispose individuals to engage in risky drinking behavior, the capacity to endure distress might play a lesser role in this specific behavior, at least in the studied population. This finding invites a deeper examination of alternative mechanisms underpinning heavy episodic drinking.
Moreover, the analysis accounted for the moderating effect of therapeutic cannabis use. Interestingly, cannabis co-use did not blunt or exacerbate the relationships between psychological inflexibility, distress tolerance, and the other substances, indicating that the psychological drivers of cigarette dependence and binge drinking may operate independently of cannabis use in therapeutic contexts. This dissociation emphasizes the importance of addressing individual psychological traits directly rather than attributing co-use solely to cannabis-related factors.
This research lends itself to important clinical implications. Given that psychological inflexibility emerges as a key factor linked not only to cigarette dependence but also risky alcohol use, therapeutic paradigms emphasizing increased psychological flexibility — such as Acceptance and Commitment Therapy (ACT) — could be pivotal in treating substance dependencies, specifically among consumers of therapeutic cannabis. Additionally, building distress tolerance skills may complement such interventions to reduce tobacco use, especially among those with a high dependency profile.
The detailed examination of distress tolerance nuances adds to a growing recognition that the ability to endure psychological distress without resorting to substance use is crucial for successful recovery. Low distress tolerance can trigger automatic relapse or maintenance of dependence through immediate self-medication with cigarettes or alcohol. Understanding individual variation in distress endurance offers a valuable target for interventions geared toward relapse prevention, particularly when integrated with strategies aimed at fostering psychological flexibility.
Notably, the sample focused on in this study represents a unique cohort at the crossroads of medical cannabis use and conventional substance use behaviors. Their particular psychological profiles reflect complex interdependencies that may not manifest identically in other populations, such as recreational cannabis users or those with no cannabis history. Hence, extrapolating these findings to the broader public necessitates careful consideration of contextual factors including motivation for cannabis use and co-occurring psychiatric disorders.
Furthermore, this study provides a methodological template for future addiction research. By parsing the individual and combined influences of psychological inflexibility and distress tolerance on polysubstance use, the study advances our understanding of addiction beyond simplistic cause-effect models. It highlights the necessity of multidimensional assessment protocols that capture the interplay of cognition, emotion regulation, and behavioral patterns to better predict and mitigate substance-related harms.
As public health landscapes evolve with increasing acceptance and utilization of cannabis for medical purposes, insights from such research assume greater importance. Tailoring treatment and harm reduction strategies to incorporate psychological flexibility training and distress tolerance enhancement can potentially curb the concurrent risk behaviors of cigarette dependence and binge drinking, which remain leading contributors to morbidity and mortality worldwide. This dual focus could optimize outcomes among therapeutic cannabis users, a group whose substance use profiles challenge conventional intervention approaches.
In conclusion, the study by Agterberg and colleagues marks a significant contribution to mental health addiction literature by deciphering the psychological underpinnings of cigarette and alcohol dependence in the context of therapeutic cannabis co-use. Their findings underscore psychological inflexibility as a critical target for intervention, while also illuminating the nuanced role of distress tolerance in tobacco dependence. These revelations open avenues for integrating acceptance-based psychotherapies into addiction treatment paradigms tailored for medicinal cannabis users, ultimately aiming to reduce harms associated with multiple substance dependencies.
As addiction science embraces increasingly individualized approaches, understanding and modifying psychological flexibility alongside distress tolerance emerges as a promising frontier. This research highlights how advancing our grasp of internal psychological processes can translate into tangible public health benefits, reducing the burden posed by cigarette and alcohol use even within medically supervised cannabis consumers. The insights offered here pave the way for innovative, psychologically informed treatment frameworks and preventative strategies.
Looking forward, further investigations incorporating longitudinal data and neurobiological correlates could enrich our comprehension of these relationships. Enhanced cross-disciplinary methodologies may unravel causal pathways and identify biomarkers for psychological inflexibility and distress tolerance, facilitating early identification and targeted intervention. Such progress would represent a crucial step toward personalized medicine in addiction treatment.
In the interim, clinicians and addiction specialists working with therapeutic cannabis users are encouraged to assess psychological flexibility and distress tolerance as part of comprehensive evaluations. Incorporating this knowledge can improve prognosis and guide individualized care plans designed to mitigate cigarette dependence and risky alcohol consumption. Ultimately, this integrative approach holds promise for addressing the multifactorial challenges of substance use within complex clinical populations.
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Agterberg, S., Bridgeman, M.B., Billingsley, B. et al. Examining the Roles of Psychological Inflexibility and Distress Tolerance on Cigarette Dependence and Binge Drinking among Individuals who Co-use Cannabis for Therapeutic Purposes. Int J Ment Health Addiction (2025). https://doi.org/10.1007/s11469-025-01594-z
Image Credits: AI Generated
DOI: https://doi.org/10.1007/s11469-025-01594-z
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