As a frequent cannabis consumer and an expert in substance use, I have long been bothered by the way cannabis use is categorized and more importantly, evaluated. As a professor at Berkeley, I taught about the traditional use of the DSM in my Substance Abuse Treatment course, but not without a thorough critique. For those not familiar, the DSM or Diagnostic Statistical Manual, is what mental health professionals use to diagnose every psychological condition, including drug addiction. (Not so fun fact, homosexuality was in the DSM as a mental health disorder until 1974 and was only removed after work by gay activists). DSM diagnoses are not just a guide for treatment plans, they are required by insurance companies in order for treatment to be covered. Drug use in the DSM is especially interesting because many of the qualifiers for drug addiction have been more about the illegal status and stigma of drug use, than harms from actual consumption. For example until 2013, the assessment for cannabis dependence included questions about getting in trouble with the law. The DSM also distinguishes between substance abuse and dependence based on the number of conditions being experienced and the presence/absence of withdrawal symptoms. If withdrawal symptoms exist, use is defined as “dependence”. If hazardous use exists without withdrawals, then use is likely defined as “abuse”. There is also a category for substance induced disorders that are said to have arisen from the use itself. So, what does this have to do with cannabis?
Cannabis has long been a thorn in the side of the DSM. While cannabis dependence, abuse and withdrawal exist, the medical utility of cannabis along with the variability in dependence symptoms among consumers makes it difficult to assess use based on the realities of consumption with standard DSM tools. Indeed, because cannabis use, dependence and abuse can be complicated, in 2013, the DSM combined cannabis abuse and dependence into Cannabis Use Disorder (CUD). Craving was added to the list of criteria, which now stands at eleven: hazardous use, social/interpersonal problems, neglected major roles, withdrawal, tolerance, used larger amounts/longer, repeated attempts to quit/control use, too much time spent using, physical/psychological problems related to use, activities given up in order to use, and craving. CUD is also divided into three levels, mild, moderate and severe. To meet the mild diagnosis, patients only have to report experiencing 2-3 of the 11 criteria. But I think it is more nuanced than that given that most cannabis consumers use for both recreational and medical purposes and what this means for classically defined "dependence". To dive a little deeper, I conducted an online survey of cannabis consumers to see how often withdrawals and other indications of CUD like using more than intended and not being able to stop were occurring.
One hundred and twenty four people completed the survey. Sixty five percent identified as women. Ninety two percent have some type of legal access to cannabis where they live with 72% living in an adult use market. Eighteen was the most common age of first use (15%) but age of initiation ranged from 11-56. Sixty two percent report consuming cannabis everyday and 22% consume 5+ times on those days, while 16% consume no more than once. This implies that even those who consume everyday have varying consumption patterns. Sixty two percent prefer smoking flower. However, when asked what is the most common way of consuming, smoking flower dropped to 57% and there were increases in edibles and vaporizing flower, showing that consumers are engaging in harm reduction by substituting their favorite but less healthy method with one that they prefer less, but might be better for them. Importantly, 82% report using for both medical and recreational purposes and 68% have ever had a medical cannabis card. This will be important when we discuss the evolved view of “dependence” later on. Relaxation, reducing anxiety and help with sleep were the top reasons for use. Three quarters said that they take the right amount of cannabis every time, but 11% said they rarely or never take the right amount.
Thirty seven percent report needing the same dose now as they did 5 years ago, while 32% said they need more now and 25% said they need less. One of the ways the DSM seeks to diagnose substance dependence is needing more over time to get the same effect. As can be seen with this survey, cannabis does not work that way for everyone, not even regular consumers. The most common side effect reported was dry mouth (71%) and red eyes (58%). The DSM also asks about the presence/absence of negative effects. In this sample, 32% reported experiencing anxiety and 28% have experienced paranoia. Furthermore, 22% reported feeling uncomfortable feelings of disassociation, and 15% report work disruption due to their cannabis use. This implies that while benign effects are most common, cannabis use is not without risk. Also, even in legal states, the memory of prohibition can increase the risk of anxiety and paranoia around using cannabis. Sixty six percent report taking a break from cannabis in the past year, and 24% reported experiencing some sort of withdrawals during that break. Eleven percent reported trying to take a break unsuccessfully, and 35% said sometimes they consume more cannabis than they intend to. Finally, 16% said they would or might be interested in learning how to change their cannabis use. So yes, some behavior patterns among regular consumers fit into the DSM paradigm, but many don’t. And, given that many regular consumers can take breaks without withdrawals and the frequency with which people use cannabis for both medical and recreational purposes warrants a new paradigm to describe modern use. So, without further ado….
It is important to acknowledge not only the various patterns of use, but the motivations behind them and a realistic sense of potential harm. Here is my Cannabis Use Typology (CUT)
Occasional Use: This refers to those who use cannabis every once in a while. They likely do not purchase it themselves, or they might purchase a small amount that lasts them all year. They have no desire to increase their use and cannabis is not a tool they use to cope with stress or celebrate victories.
Regular Use: This refers to those who use cannabis fairly regularly (at least 3 times a week), but often go long periods of time without it, and do not use it as a tool to cope, but may use it as one to celebrate. This consumer may go long periods of time without consuming if they are traveling or someplace away from home. They likely do not make arrangements to take it with.
Habitual Use: This refers to use that has become a habit. Habits are behaviors that we do because they are part of our routine. Brushing our teeth, checking email in the morning, these are habits. If we don’t do them, we don’t have withdrawals, but we might feel like something is missing and feel the urge to complete the behavior. However, habitual use does not necessarily equal addiction, or even dependence. It speaks more to how cannabis presents as part of our life rhythm and routine.
Dependence: Before people start yelling at the article, hear me out. DEPENDENCE DOES NOT MEAN ADDICTION! Diabetes patients are dependent on insulin. Those with OCD can be dependent on Lexapro. All this means is that a person needs this medicine in order to stave off symptoms and/or maintain wellness. I am a habitual consumer of cannabis and I am dependent on it to quell the symptoms of my arthritis, which are quite painful. My dependence on cannabis has prevented my potential dependence on opiates. The point being, not only is dependence a neutral circumstance, it may be preventing dependence on a more dangerous substance.
Hazardous Use: Here is the first time that the DSM may be useful in identifying consumers who may experience harm. These are people who consume and then engage in hazardous behavior (e.g. driving while intoxicated, performing certain duties while intoxicated like surgery). If use is leading to behaviors that might be dangerous, a re-evaluation of use might be in order. If this is the case, it is important to manage the potential harm and bring awareness to use motivations, WITHOUT JUDGMENT (see part one for more on that!)
Addiction: I know that many will scoff at the idea of cannabis addiction, but it is real. And while some people who are put in this category actually belong elsewhere in this use typology, there is a group of folks who have a genuine addiction to cannabis. So, what does this look like? For one, persistent use despite a desire to stop or cut down. Withdrawal symptoms upon cessation (usually insomnia, irritability, lack of appetite), and/or use despite consequences (e.g. using even though you are subject to drug testing, have a medical condition which discourages use or risk legal consequences from using). These may be indicators of cannabis addiction. There are many options for people who feel they have this issue, with cognitive behavioral therapy being a popular one.
A few words about harm reduction and mindful consumption. In part one, we explored the concept of mindful consumption as awareness without judgment. Honestly and objectively looking at your cannabis use patterns not only in terms of risks and benefits but harm avoided is important. In 2009 I published one of the first studies on the use of cannabis as a substitute for alcohol and other drugs. The practice of using cannabis instead of more harmful substances is now well documented. Some risks associated with cannabis are more benign than those of other medications and certainly compared to alcohol. Choosing cannabis can be a good health decision, but that doesn't mean that all use is medical, or even beneficial. Removing judgement and becoming aware of your motivations for cannabis use as well as how you fit into the Cannabis Use Typology is an act of mindful consumption as well as harm reduction. In the final article of this series, we will explore specific methods for using cannabis as a substitute for alcohol and prescription drugs.
The trope of “all drug use is abuse” has made it tough to see past the all or nothing thinking of assessments like the DSM and recognize the many faces and types of cannabis consumption that exist today. The most important takeaway from BOTH parts one and two of is that everyone is doing the very best they can. Awareness of motivation for behaviors without judgment is at the center of developing healthy relationships with cannabis and other psychoactive plants.