Challenging assumptions around marijuana addiction

marijuana addiction
An attendee vapes a CBD oil pen made from hemp at the Cannabis World Congress Conference on June 16, 2017 in New York City. SOURCE: Spencer Platt | Getty

When Americans imagine the ravages of addiction, marijuana is far from the first drug that comes to mind. Indeed, in decades of covering drug policy, I’ve never met a family member of a person with alcoholism, heroin addiction or cocaine addiction who wouldn’t overwhelmingly prefer that their loved one’s drug of choice was cannabis— if abstinence wasn’t an option.

Unfortunately, marijuana can still be addictive and marijuana addictions can be harmful. Understanding why offers insight into what addiction really is and what matters most for effective treatment and policy—from weed to heroin. And no, this doesn’t mean that criminalization is the best response.

Simply put: ‘addiction’ is now defined as ‘compulsive behavior despite negative consequences’. That’s different from ‘physical dependence’ — which is when the body needs a drug to function regularly. Let’s look at the terms’ evolution.

The ‘Physical’ vs ‘Psychological’ Addiction Fallacy

The challenge started in the language we’ve traditionally used to define addiction. When I was introduced to marijuana in the 1980s, conventional wisdom had it that “physical dependence” was the essence of the problem— if you could quit a drug without the ordeal of a week or more of puking, shaking, sweating and diarrhea, it wasn’t really addictive. This took marijuana off the table.

Instead, heroin, alcohol and anxiety drugs like Valium were the exemplars of addiction: their withdrawal symptoms are obvious and in the case of alcohol and benzodiazepines— and even opioids, if you are incarcerated without access to medical care— can actually be deadly. Quitting cocaine or marijuana, however, doesn’t cause such physical distress.

As a result, both coke and pot were seen as merely “psychologically addictive”— and, of course, anyone with any type of self-discipline would never need to worry about managing that. In 1982. Scientific American even declared that snorting cocaine was no more addictive than potato chips.

experts recognized that the “physical” versus “psychological” distinction wasn’t helpful

Then, however, came crack. With its rapid spread came the realization that cocaine could produce addiction problems every bit as serious as those seen with heroin. Soon, experts recognized that the “physical” versus “psychological” distinction wasn’t helpful: in fact, the psychological drive involved in addiction is actually far more important in determining relapse and recovery than the severity of physical withdrawal symptoms. (And besides, scientific reductionism means that psychology has to be represented in the physicality of the brain somehow.)

Medicine and psychiatry’s diagnostic manual— the DSM— didn’t face up to this problem until recently. In 1989, in a misguided attempt to reduce stigma by avoiding the term “addiction,” the DSM declared that “substance dependence” would be the politically correct clinical term. Sadly, however, this exacerbated the problem, unintentionally reinforcing the idea that physically or psychologically needing a substance to avoid withdrawal is the core of addiction.

And that caused real problems for pain patients, people with opioid addiction who need opioid medications to treat it— and those who genuinely do struggle to control or end their marijuana use. Here’s why.

If addiction and dependence are the same thing, everyone who takes opioids for long enough — even if they are treating pain — is considered ‘addicted’. If they are the same, everyone who needs some kinds of antidepressants or certain medications for blood pressure is ‘addicted’ — since they can cause withdrawal and are required for functioning. And if they are the same, using medication to treat addiction is just ‘replacing one addiction with another’— even if the person on the medication is never high, is not impaired and has moved from a life of crime and desperation to having a successful career and strong family.

The New Focus on ‘Compulsion’

Experts now recognize that the real problem in addiction isn’t the need for the substance— it’s the compulsive behavior that continues despite negative consequences. If addiction were simply need, we’re all addicted to air, water and each other (human stress systems do not function well without social contact, which is why solitary confinement is so harmful). The idea becomes meaningless: if dependence doesn’t involve harm, why should anyone care about it?

You can be addicted to fast food, television, video games, social media, or masturbation.

Only if we recognize—as DSM 5 and the National Institute on Drug Abuse now do— that the compulsion to use, the difficulty maintaining control over use and the inability to stop when you want to do so or when use is harming you is what matters can we truly understand addiction. You can be addicted to fast food, television, video games, social media, or masturbation. None of them cause physical dependence, but some people just cannot stop even though they want to.

And this is why marijuana can indeed be ‘addictive’ — about 9% of marijuana users do suffer from compulsive use of the drug that persists despite harm. While marijuana addiction is less likely to occur than addiction to other substances — and it doesn’t tend to cause the dramatic decline seen with opioids, methamphetamine or alcohol — associated problems can nonetheless be insidious.

Instead of ruining relationships, marijuana addiction might subtly worsen them; rather than causing job loss, it might quietly reduce productivity and likelihood of promotion, or lower educational achievement; instead of destroying a life, it may simply make it less rich than it might otherwise have been. The fact that marijuana is generally less harmful than other substances is obviously a good thing— but the lack of extreme negative consequences in many cases of marijuana addiction can also mean that the need for change feels less urgent.

Understanding the nature of all types of addictions, then, can allow better treatment and policy. Because addiction persists despite negative consequences, using the criminal justice system is not a good way to deal with it — whether the drug is marijuana or anything else. Because marijuana addiction in particular is harder to recognize and address, treatment for it needs to be customized and mental illnesses anxiety, depression, post-traumatic stress disorder, attention deficit hyperactivity disorder that often underlie it appropriately treated. Teen treatment particularly needs to be improved: the current system places teen marijuana users in rehab with those with opioid, cocaine and methamphetamine problems, which tends to make matters worse, not better.

We now have a much better handle on what addiction is (persistent behavior despite negative consequences) — and what it isn’t (physical dependence). But the greatest challenge is to change the system so that these insights can inform policy and practice.

Maia Szalavitz is a neuroscience journalist and author of the “Unbroken Brain: Why Addiction Is a Learning Disorder and Why It Matters.”