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The field of psychology is abuzz this month because our manual for diagnosing clinical disorders is being re-released and will be chock-full of modifications (DSM-5). The proposed changes are particularly relevant to my own work because the newest edition is reorganizing how we diagnose cannabis related disorders. The most notable change is the addition of “craving” as a key criterion to receive the diagnosis of cannabis use disorder. To demonstrate why this move might be premature let me tell you a quick story.
For the past two summers I’ve had the blissful experience of interning at a wellness centre in the rainforest of Queensland, Australia. The retreat is all about holistic wellbeing, so diet is strictly monitored. Food is all organic and perfectly balanced for proper nutrient absorption.
Of course my body always feels amazing being here, but with one interesting side effect. I crave sugar like a crazy woman! What’s weird is I don’t normally crave sweets. Not at all. I’m more the savory-salty type. But when my body isn’t getting all the extra sugar in my way-too-carb-heavy diet or from those glasses (er… bottles) of wine I regularly share with friends it apparently goes into give-me-sugar-this-second mode. On my days off I would find myself freaking stoked to go into town and get a chocolate bar, yippee! For all intents and purposes I was craving, right?
My craving experience likely wasn’t just nominal either. There would have been actual neuroadaptation occurring during those weeks of crap-food detox that led to my psychological state. My body had previously gotten used to a certain amount of sugar in my diet and the restriction led to a compensatory response where my brain said something’s not right here, where’s the sugar?
My experience was that I was really excited about the prospect of a sweet treat and I found a way to go and get one. But was this experience indicative of some kind of underlying pathology? I don’t think so. Sure, we can see how it could be. Disordered binge eating would show features of uncontrollable craving. But, even if I gave in and bought a chocolate bar (don’t worry it was like 90% dark) when the craving hit, would this state be worrisome? I wanted it, and I gave in and had it. Is this process pathological? I’m not so sure.
To make my point let me contrast this with another experience I had at this amazing resort. Most of the clients who came here were looking to get healthy: lose weight, quit drinking, stop smoking. The retreat was very elite and kept enrollment to a minimum. Group dynamics were considered key to people’s change process. One bad egg could spoil the bunch, and by my third week of work I witnessed my first “bad egg.” The man was in his early 30s. He arrived at the health retreat by limo (understated), accompanied by a nice billow of cigarette smoke.
Sure enough, he was there to quit smoking. After attempting several times before, he’d decided to invest two weeks and around ten grand to make it happen. I think you already know where this is going… By the second day the man was in full-blown crave mode. He was yelling at staff, refused to join activities, kept making exasperated sighing noises during morning Qigong, and all but punched the yoga instructor when she commented on his “negative energy.” Day three hit and he was not a happy camper. The man was irritable, sweaty, and had to be told by management to calm his tits because he was disturbing the other guests. Okay, my guess is they didn’t say, “Calm your tits,” but you get the point.
That night, he snuck out of a $10,000 gated health retreat to march 10 kilometers down a mountain to the nearest town to get a cigarette. When the GM found out, the ciggie-man was sent packing. He lost out on his entire deposit. This is starting to sound more like craving now, right?
So what’s the difference between this man’s experience and my chocolate fix? Is it just that his actions were more extreme? Was it that his “craving” was more intense? Can we call both of these states craving? And more importantly to the new DSM changes, do both of these states indicate psychopathology? The nicotine addict who keeps relapsing, despite intentions to quit, due to overwhelming cravings is a pretty clear example.
Here it’s seemingly intuitive that craving and addiction should run hand in hand. In fact, the push to include craving in the new diagnostic manual came from actual practitioners who reported it was their client’s reports of “craving” which led the therapist to diagnose them with a substance use related disorder. The move for inclusion of craving was a decision informed by individual reports and not from empirical evidence (glad we’re doing all this research people—don’t mind us!). Nevertheless, it doesn’t sound far off base does it? If one of my girlfriends told me she was really craving some crack-cocaine, I’d probably get a little nervous.
Now how about cannabis? For the marijuana connoisseur the idea of experiencing an overwhelming urge to smoke pot and then smoking (or drinking, eating, dabbing, vaping, yeah yeah I get it), doesn’t sound like a disordered state. And yet the clinical feature of “urgency to use” or “strong desire” is the exact clinical definition of drug craving.
“Now how about cannabis? For the marijuana connoisseur the idea of experiencing an overwhelming urge to smoke pot and then smoking (or drinking, eating, dabbing, vaping, yeah yeah I get it), doesn’t sound like a disordered state. And yet the clinical feature of “urgency to use” or “strong desire” is the exact clinical definition of drug craving.”
This is where I think things get hairy again, so let’s turn back to the fat farm. After hearing about my lovely experience interning at the resort a close girlfriend, and at the time daily cannabis user, also began work at the retreat. She struggled for a few days with adjusting to not having her daily medicine. Little things we did throughout the day seemed to trigger her memory of smoking. She mentioned more than once some bud sounded pretty darn good. But at any point did she slink off in the night to find a dealer? Hardly. The choice to forgo cannabis wasn’t ideal, but it wasn’t purgatory either. My girlfriend’s experience suggests there are two questions psychologists need to be asking:
1. Do cannabis users actually show craving in the sense of ‘jonesing’ or needing a fix?
2. If they do, does this “craving” really function the same as it would for other controlled substances as an indication of dependency or abuse?
For the first question, it really becomes an issue of semantics. The term “craving” is ambiguous. It’s going to hold different weight for a tobacco, or let’s even get more extreme– methamphetamine user– than it would in explaining my experience during those lovely weeks when I’d make my way to a chocolate shop on days off. Even among cannabis users, some report “yes, I crave pot all the time,” whereas others will say “not possible.” Likely, what the term “craving” means to any one person will influence how they answer the question, “are you craving ____ right now?”
This becomes even messier when talking about a substance that’s used to both alleviate pain and/or have a psychedelic experience. If the effects of cannabis are subjective, dependent on the intentions and state of the user, and vary widely, then wouldn’t it follow that long-term effects would have the same features? To complicate this, my lab even has new research suggesting that just believing that a substance is capable of producing dependency and states of craving will make you more likely to actually experience craving when you use. Far out huh? But more on this later. So what is it we’re talking about? Is cannabis craving the same as liking? Wanting? Urgency? And, are those terms actually analogous? I think you see now how complicated this can get.
“Just believing that a substance is capable of producing dependency and states of craving will make you more likely to actually experience craving when you use.”
The second question, which is probably more relevant to whether or not the changes to the DSM are worthwhile, asks whether craving of marijuana acts functionally the same in terms of maintaining problematic substance use as it does for other drugs. This is where the research fails. All studies cited by the APA task force responsible for the new addition were based on research that used alcohol and cocaine abusing samples.
Let me state that again, no empirical research studies on marijuana users informed the decision to add craving as a diagnostic criteria for marijuana related disorders in the most widely used diagnostic manual for mental health professionals. But do those studies exist? Yes. And what do they say? The few studies (I mean very few) that investigated this question using marijuana users suggest that the new diagnostic scheme over identifies users as problematic. This might not seem like a major issue; wouldn’t we rather be on the safe side? But the change means that we will likely see an increase in prevalence of cannabis related disorder diagnoses unnecessarily. Someone will be told they are an addict when they may or may not be. Now, if you believe in the old adage “once an addict, always an addict,” you’ve just set someone up for failure for the rest of his or her life. This also isn’t going to look too good for all those folks tracking whether the new legalization laws correspond with increases in marijuana related problems.
“Let me state that again, no empirical research studies on marijuana users informed the decision to add craving as a diagnostic criteria for marijuana related disorders in the most widely used diagnostic manual for mental health professionals.”
My other beef with this change is that little issue of veracity. Psychology practitioners, who don’t necessarily have time to constantly scour the literature on every disorder, are being told this is what the latest research suggests about cannabis use disorders. The changes will impact how professionals conceptualize marijuana misuse. Not only that, but the whole change is based on a presumption that all substances of abuse function the same in terms of problem development. If the APA task force cited alcohol and cocaine studies as the informants for changes to marijuana related disorders, than this presumes that marijuana “addiction” functions and shows similar clinical features to cocaine “addiction.” I hate to be crude, but I think we can really hit the nail on the head with Bob Saget’s quote in half-baked when he stated, “I used to suck dick for coke. You ever suck dick for marijuana?”
The assumption that all drugs are the same might also be a reflection of pervasive beliefs within the culture at large.
Marijuana is bad because it’s a drug. It’s as if “drug” represents one specific homogenous group. We categorize all hallucinogens, depressants, stimulants, and opioids as “drugs,” and, therefore, assume they have something in common. This cultural context might explain some of the resistance to legalization efforts of marijuana as well if people really aren’t differentiating marijuana from other illicit substances. Our society’s conceptualization of “craving” also seems to follow this pattern of presumed homogeneity. We believe that we have a general understanding of what “craving” means, and yet its only after stopping to parse it out that we see how the definition and function takes on a unique flavor depending on how we’re referring to it (e.g. chocolate versus nicotine). Do people really jones for weed? Who knows? Which is why this move really is premature. All I know is I won’t be rushing my girlfriend to rehab the next time she tells me she really really wants to smoke some pot.