Cannabis Dependence a real dependence?

1) Public Health Sciences, University of Toronto 2)Centre for Addiction and Mental Health, Toronto 3) ISGF Zurich, Switzerland 4) TU Dresden. Germany

Jrgen Rehm1,2,3,4

Definition: what has been labeled dependence

Overview of last 50 years in major classifications (work partly published by Room, Drug & Alcohol Review, 1998)

Addiction vs. Habituation in 1957

Drug addiction
... a state of periodic or chronic intoxication produced by the repeated consumption of a drug ... Its characteristics include: 1. an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; 2. a tendency to increase the dose; 3. a psychic (psychological) and generally a physical dependence on the effects of the drug; 4. detrimental effect on the individual and on the society.

Drug habituation
... a condition resulting from the repeated consumption of a drug. Its characteristics include: 1. a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; 2. little or no tendency to increase the dose; 3. some degree of psychic dependence on the effects of the drug, but absence of physical dependence and hence of an abstinence (withdrawal) syndrome; 4. detrimental effects, if any, primarily on the individual.

Addiction vs. Habituation in 1957 cont. Addiction-producing drugs need strict control, national and international; for habit-forming drugs the warning (label) and national control measures should suffice,... but any warning concerning habituation should not carry the stigma of addiction.
Source: WHO Expert Committee on Addiction-Producing Drugs, Seventh Report (1957) pp. 9-10, 14.

Alcohol and drug disorders in three successive editions of the International Classification of Diseases
ICD-8, 1965
303 .0 .1 .2 Alcoholism Episodic excessive drinking Habitual excessive drinking Alcoholic addiction 305 .0

ICD-9, 1975
Non-dependent abuse of drugs Alcohol (includes acute intoxication and hangove r)

ICD-10, 1992
F1x.0 Acute intoxication F1x.1 Harmful use

.2-.8 (other drugs) .1 303 Tobacco dependence Alcohol dependency syndrome Drug dependence Drug psychoses Drug withdrawal syndrome (drug psychoses ) Pathological drug intoxication F1x.2 Dependence syndrome

304 294

Drug dependence

304 292 .0 .1,.8 .2

Psychoses associated with other physical conditions .3 Drug or poison intoxication (includes psychos is associated with drug addiction or dependence ) 291 Alcoholic psychoses .0 Delirium tremens .1-.3,.9 (various alcoholic psychoses )

F1x.3 Withdrawal state F1x.4 Withdrawal state with delirium F1x.5 Psychotic disorder F1x.6 Amnesic syndrome F1x.7 Residual and late-onset psychotic disorder

291 Alcohol psychoses .0 Delirium tremens .1-.3,.5-.9 (alcoholic psychoses ) .4 Pathological drunkenness .8 other (includes alcohol withdrawal syndrome)

Drug dependence makes its debut, 1964

Drug dependence of... Desire or need to take Tolerance Psychic Physical dependence dependence & hence withdrawal + + + + + + + -

Morphine type Barbiturate type Cocaine type Amphetamine type Cannabis type

overpowering + strong + overpowering + + +

+ + + -

*a psychic dependence on the effects of the drug related to a subjective and individual appreciation of those effects. Source: WHO Expert Committee on Addiction-Producing Drugs, Thirteenth Report (1964), pp. 9, 13-15. (subheading:) Drug dependence to replace the terms drug addiction and drug habituation. (There is a need) to find a term that could be applied to drug abuse generally. The component in common appears to be dependence, whether psychic or physical or both. Hence, the use of the term drug dependence, with a modifying phrase linking it to a particular drug type.

Four versions of alcohol dependence in the Anglo-American tradition

Edwards & Gross (1976) Withdrawal Use to relieve withdrawal Tolerance Use involves neglecting interests or important activities Much time spent obtaining, using, recovering Use despite evidence of harmful consequences Use more than intended Persistent desire or unsuccessfu l efforts to cut down Strong desire or sense of compulsion Narrowing of drinking repertoire Rapid reinstatement Impairment of social or occupational functioning Dependence diagnosis: DSM-III: (withdrawal or tolerance) and (pathological use or impairment of functioning); DSM-IV: any 3 of 7; ICD-10: any 3 of 6. compulsion pathological use salience DSM-III (1980) DSM-IV (1994) ICD-10 (1992)

preoccupation

impaired control

Conclusion on definition: what has been labeled dependence There have been many attempts to define dependence over the past 50 years which were partly contradictory. There is some agreement now which may change dramatically with neurobiological results coming in (craving, withdrawal, tolerance producing mechanisms).

Criteria in a cross-cultural perspective quantitative aspects

Based on WHO/NIH joined project on reliability and validity: Amsterdam, NL; Ankara, Turkey; Athens, Greece; Bangalore, India; Farmington, US; Ibadan, Nigeria; Luxembourg, Luxembourg; Jebel, Romania; San Juan, Puerto Rico; St. Louis, US; Sydney, Australia (partly taken from Nelson et al., Addiction, 1999)

Prevalence across centres

Differences in absolute prevalence (sampling) but also in rank: ICD 10 cannabis dependence: use despite harm is lowest prevalent in Bangalore, but third highest in Amsterdam and St. Louis ICD 10 cannabis dependence: withdrawal is lowest in all centres except Bangalore where it is third highest DSM IV cannabis dependence: activities limitation is highest in Ankara, but lowest in Amsterdam with others in between

Criterion Prevalence for Abuse among Users of different substances - DSM IV

Criteria for abuse failure in role physically hazardous legal problems social/interpersonal problems Abuse diagnosis

Alcohol 39 43 14 35 18

Cannabis 14 25 7 15 13

Cocaine Opiate 67 47 29 64 3 74 49 28 68 4

Criterion prevalence for dependence among users of different substances DSM IV criteria
Criteria for dependence tolerance withdrawal more than intended unsuccessful cut-backs great deal of time activities limitation physical/psychological problems Dependence diagnosis Alcohol 50 29 48 42 34 34 31 45 Cannabis 22 18 23 29 21 19 13 24 Cocaine 57 48 71 70 67 66 51 72 Opiate 66 81 68 81 72 74 64 81

Prevalence across instruments

Different instruments had different kappas regarding different criteria for different substances: Average kappa with psychiatric judgment cannabis: 0.1 for AUDADIS, 0.2 for CIDI, 0.2 for SCAN Not a very good result, and clearly lower than for all other substances! However, this may be due to psychiatric judgements.

Cannabis dependence, OSDUS

20 15

Percentage of past year cannabis users reporting 1+ dependence symptoms, OSDUS, 2005

10
8.2

9.2 7

9.6

10.2 7.8 6 7.8

11.1 9.3

6.1

0 Total M F G9 G10 G11 G12 TO N W E

Vertical bars rep resent 95% confidence intervals; horizonta l bar represents 95% CI for to tal estimate; suppressed estima tes fo r G7 and G8

Cannabis dependence
In self-reports, we see relatively high rates of endorsement of symptoms for cannabis dependence, even in adolescent students. Student also can make sense of these symptoms, i.e. no problems with questions.

Hazard Ratio=1.56, 95%CI=[1.03-2.37], p=0.036

Cumulative lifetime incidence of cannabis use disorder
0.5 0.45 0.4

Proportion

0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 0 5 10 15 20 25

no prior mental disorder (N=559) prior mental disorder (N=751)

Age

High OR for other mental disorders with cannabis use disorders: -5.7 for any mental disorder - 6.0 for any mood disorder, 2.2 for any anxiety disorder - 7.9 for any substance use disorder, 60 for illicit drug use disorder Cannabis use disorders show similar relationships to other psychiatric disorders as alcohol or other substance use disorders! Wittchen et al., 2007

Cannabis dependence: is it real?

Cannabis dependence is real given the current definition. However, the concept and the definiton may change in the next years, depending on the developments of DSM V or ICD 11.