Alan J. Budney

DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale

Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, adding cannabis and caffeine withdrawal syndromes, aligning tobacco use disorder criteria with other substance use disorders, and moving gambling disorders to the chapter formerly reserved for substance-related disorders. The proposed changes overcome many problems, while further studies will be needed to address issues for which less data were available.

The Time Course and Significance of Cannabis Withdrawal

Withdrawal symptoms following cessation of heavy cannabis (marijuana) use have been reported, yet their time course and clinical importance have not been established. A 50-day outpatient study assessed 18 marijuana users during a 5-day smoking-as-usual phase followed by a 45-day abstinence phase. Parallel assessment of 12 ex-users was obtained. A withdrawal pattern was observed for aggression, anger, anxiety, decreased appetite, decreased body weight, irritability, restlessness, shakiness, sleep problems, and stomach pain. Onset typically occurred between Days 1-3, peak effects between Days 2-6, and most effects lasted 4-14 days. The magnitude and time course of these effects appeared comparable to tobacco and other withdrawal syndromes. These effects likely contribute to the development of dependence and difficulty stopping use. Criteria for cannabis withdrawal are proposed.

The cannabis withdrawal syndrome.

Purpose of review The demand for treatment for cannabis dependence has grown dramatically. The majority of the people who enter the treatment have difficulty in achieving and maintaining abstinence from cannabis. Understanding the impact of cannabis withdrawal syndrome on quit attempts is of obvious importance. Cannabis, however, has long been considered a ‘soft’ drug, and many continue to question whether one can truly become dependent on cannabis. Skepticism is typically focused on whether cannabis use can result in ‘physiological’ dependence or withdrawal, and whether withdrawal is of clinical importance. Recent findings The neurobiological basis for cannabis withdrawal has been established via discovery of an endogenous cannabinoid system, identification of cannabinoid receptors, and demonstrations of precipitated withdrawal with cannabinoid receptor antagonists. Laboratory studies have established the reliability, validity, and time course of a cannabis withdrawal syndrome and have begun to explore the effect of various medications on such withdrawal. Reports from clinical samples indicate that the syndrome is common among treatment seekers. Summary A clinically important withdrawal syndrome associated with cannabis dependence has been established. Additional research must determine how cannabis withdrawal affects cessation attempts and the best way to treat its symptoms.

The co-occurring use and misuse of cannabis and tobacco: a review

AIMS   Cannabis and tobacco use and misuse frequently co-occur. This review examines the epidemiological evidence supporting the life-time co-occurrence of cannabis and tobacco use and outlines the mechanisms that link these drugs to each other. Mechanisms include (i) shared genetic factors; (ii) shared environmental influences, including (iii) route of administration (via smoking), (iv) co-administration and (v) models of co-use. We also discuss respiratory harms associated with co-use of cannabis and tobacco, overlapping withdrawal syndromes and outline treatment implications for co-occurring use. METHODS   Selective review of published studies. RESULTS   Both cannabis and tobacco use and misuse are influenced by genetic factors, and a proportion of these genetic factors influence both cannabis and tobacco use and misuse. Environmental factors such as availability play an important role, with economic models suggesting a complementary relationship where increases in price of one drug decrease the use of the other. Route of administration and smoking cues may contribute to their sustained use. Similar withdrawal syndromes, with many symptoms in common, may have important treatment implications. Emerging evidence suggests that dual abstinence may predict better cessation outcomes, yet empirically researched treatments tailored for co-occurring use are lacking. CONCLUSIONS   There is accumulating evidence that some mechanisms linking cannabis and tobacco use are distinct from those contributing to co-occurring use of drugs in general. There is an urgent need for research to identify the underlying mechanisms and harness their potential etiological implications to tailor treatment options for this serious public health challenge.

Nicotine and caffeine use in cocaine-dependent individuals

Nicotine and caffeine use in 87 cocaine-dependent persons seeking treatment at an outpatient clinic were compared to use of those substances in a matched general population sample (n = 78). The prevalence of cigarette smoking was significantly greater in the cocaine-dependent sample (75% vs. 22%). Within the cocaine-dependent sample, smokers were younger, less educated, employed in lesser skilled jobs, and reported an earlier onset and more frequent use of cocaine. The prevalence of caffeine use was significantly less in the cocaine-dependent group (68% vs. 83%), although, among caffeine users, the cocaine group drank significantly more caffeinated beverages per day than matched controls (4.9 vs. 3.3). Interestingly, regular caffeine use was associated with less frequent cocaine use within the cocaine-dependent sample. To our knowledge, this study is the first to report on prevalence of smoking and caffeine use among cocaine-dependent individuals, and suggests that use of these other substances may influence the onset and pattern of cocaine use.

Initial abstinence and success in achieving longer term cocaine abstinence.

This studys goals were to characterize the relationship between early and longer term cocaine abstinence and assess whether increasing early abstinence increases longer term abstinence. Results from 190 cocaine-dependent outpatients were analyzed. Participants were divided into 2 conditions: (a) those treated with community reinforcement approach (CRA) plus contingent vouchers (n = 125) and (b) those treated with control treatments (n = 65). A period of sustained abstinence during treatment was associated with significantly greater odds of posttreatment abstinence, with no evidence of differences between the 2 treatment conditions in that regard. Treatment conditions differed in that CRA plus contingent vouchers increased the proportion of participants who sustained a period of during-treatment abstinence and increased abstinence during 6-month posttreatment follow-up. Devising interventions that increase the proportion of individuals who achieve an early period of sustained abstinence may be key to increasing longer term cocaine abstinence.

Clinical Trial of Abstinence-Based Vouchers and Cognitive-Behavioral Therapy for Cannabis Dependence

Ninety cannabis-dependent adults seeking treatment were randomly assigned to receive cognitive-behavioral therapy, abstinence-based voucher incentives, or their combination. Treatment duration was 14 weeks, and outcomes were assessed for 12 months posttreatment. Findings suggest that (a) abstinence-based vouchers were effective for engendering extended periods of continuous marijuana abstinence during treatment, (b) cognitive-behavioral therapy did not add to this during-treatment effect, and (c) cognitive-behavioral therapy enhanced the posttreatment maintenance of the initial positive effect of vouchers on abstinence. This study extends the literature on cannabis dependence, indicating that a program of abstinence-based vouchers is a potent treatment option. Discussion focuses on the strengths of each intervention, the clinical significance of the findings, and the need to continue efforts toward development of effective interventions.

Respiratory effects of marijuana and tobacco use in a U.S. sample.

OBJECTIVE: Although a number of studies have examined the respiratory impact of marijuana smoking, such studies have generally used convenience samples of marijuana and tobacco users. The current study examined respiratory effects of marijuana and tobacco use in a nationally representative sample while controlling for age, gender, and current asthma.DESIGN: Analysis of the nationally representative third National Health and Nutrition Examination Survey (NHANES III).SETTING: U.S. households.PARTICIPANTS: A total of 6,728 adults age 20 to 59 who completed the drug, tobacco, and health sections of the NHANES III questionnaire in 1988 and 1994. Current marijuana use was defined as self-reported 100+ lifetime use and at least 1 day of use in the past month.MEASUREMENTS AND MAIN RESULTS: Self-reported respiratory symptoms included chronic bronchitis, frequent phlegm, shortness of breath, frequent wheezing, chest sounds without a cold, and pneumonia. A medical exam also provided an overall chest finding and a measure of reduced pulmonary functioning. Marijuana use was associated with respiratory symptoms of chronic bronchitis (P=.02), coughing on most days (P=.001), phlegm production (P=.0005), wheezing (P<.0001), and chest sounds without a cold (P=.02).CONCLUSION: The impact of marijuana smoking on respiratory health has some significant similarities to that of tobacco smoking. Efforts to prevent and reduce marijuana use, such as advising patients to quit and providing referrals for support and assistance, may have substantial public health benefits associated with decreased respiratory health problems.

Comparison of cannabis and tobacco withdrawal: Severity and contribution to relapse

This naturalistic telephone survey study compared perceptions of withdrawal severity in 67 daily cannabis users and 54 daily tobacco cigarette smokers who made quit attempts during the prior 30 days. A Withdrawal Symptom Checklist assessed the severity of abstinence symptoms and a Likert scale assessed perceived relations between abstinence symptoms and relapse. A composite Withdrawal Discomfort Score did not differ significantly between groups (M = 13.0 for cannabis, vs. M = 13.2 for tobacco). Individual symptom severity ratings were also of similar magnitude, except craving and sweating were slightly higher for tobacco. Both groups reported that withdrawal contributed substantially to relapse, and the strength of these ratings was similar across groups. The diverse convenience sample examined in this study adds external validity and generalizability to prior studies that included only users not planning to quit or excluded many common types of cannabis users. The comparable withdrawal experience from these heterogeneous cannabis and tobacco users supports previous findings from controlled laboratory studies and indicates that real-world, frequent cannabis users perceive that withdrawal symptoms negatively affect their desire and ability to quit.

Treatment of marijuana dependence: a review of the literature

Until recently, relatively little research has focused on the treatment of marijuana abuse or dependence; however, marijuana use disorders are now receiving increased attention. This paper reviews the initial clinical trials evaluating the efficacy of outpatient treatments for adult marijuana dependence. Findings from five controlled trials of psychotherapeutic interventions suggest that this disorder appears responsive to the same types of treatment as other substance dependencies. Moreover, these initial studies suggest that many patients do not show a positive treatment response, indicating that marijuana dependence is not easily treated. Strengths and weaknesses of the data are presented. Preliminary data from less controlled studies relevant to the treatment of marijuana dependence are discussed to suggest future research areas. Although very few studies on treatment for marijuana abuse and dependence have been completed, the initial reports identify promising treatment approaches and demonstrate a need for more research on the development of effective interventions.