Reefer madness: the Controlled Substances Act & the DSM-V

Last week, the American Psychiatric Association released their recommendations for DSM-V, the new edition of the Diagnostic and Statistical Manual of Mental Disorders to be published in 2013. Should the recommendations be adopted, there are some potentially significant effects for those interested in studying, understanding or controlling substance use and abuse. In particular, several changes will most certainly impact the debate over marijuana regulation.

Marijuana is a Schedule I drug per the Controlled Substances Act (CSA), meaning that the government has deemed it 1) has a high potential for abuse, 2) has no currently accepted medical use and 3) there is a lack of accepted safety for use under medical supervision. Schedule II drugs, in contrast, have a recognized medical use subject to “severe restrictions” alongside a likelihood of severe psychological or physical dependence. Schedule III drugs have a lower potential for abuse, a currently accepted medical use and “moderate or low physical dependence or high psychological dependence.” Scheduling impacts both the criminal law (such as federal trafficking penalties) and scientific research. There also may be some impact of federal scheduling on use. Thus, while it is evident that issues with scheduling need to be looked into, the need for effective drug rehab remains.

According to 21 USC Sec. 811, the Attorney General is to consult a set of 8 factors in considering the scheduling of a substance:

(1) Its actual or relative potential for abuse.
(2) Scientific evidence of its pharmacological effect, if known.
(3) The state of current scientific knowledge regarding the drug or other substance.
(4) Its history and current pattern of abuse.
(5) The scope, duration, and significance of abuse.
(6) What, if any, risk there is to the public health.
(7) Its psychic or physiological dependence liability.
(8) Whether the substance is an immediate precursor of a substance already controlled under this subchapter.

How are we to evaluate these factors? Specifically, how do we define dependence liability and potential for abuse (which the DEA states is a “threshold issue,” but which is never defined in the CSA)? First, it is important to have a general understanding of the terms, and then to turn to marijuana, under the DSM-V.

Stanton Peele writes at HuffPo that addiction will make a reappearance in the DSM-V after it was substituted out in DSM-IV in favor of “dependence” [1]. Interestingly, the new manual will separate out substance and behavioral addictions, including gambling in the latter category. It also highlights disorders involving certain compulsive behaviors, such as “hypersexuality,” binge eating and — possibly, pending data — internet addiction. Over at Drug War Rant, though, Steele’s post inspired a discussion about marijuana addiction. Contributing blogger Danny Chapin quotes the former director of the National Institute of Drug Abuse on the real meaning of addiction:

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addiction – uncontrollable, compulsive craving, seeking and use of drugs – that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction…

Does marijuana have these effects? It might, according to the APA. DSM-V would introduce the concept of “cannabis withdrawal“ – defined as three or more of the following criteria which develop after cessation of heavy use, and which cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”:

1. Irritability, anger or aggression
2. Nervousness or anxiety
3. Sleep difficulty (insomnia)
4. Decreased appetite or weight loss
5. Restlessness
6. Depressed mood
7. Physical symptoms causing significant discomfort: must report at least one of the following: stomach pain, shakiness/tremors, sweating, fever, chills, headache.

Withdrawal is just one criterion used in diagnosing addiction. Still, this is bound to affect those who petition for marijuana rescheduling, and those who oppose it. There have been a number of petitions to reschedule marijuana since the 1970s. (For a detailed overview, see here.) In November, the American Medical Association released a new policy urging that marijuana scheduling be reviewed, “with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods.” Yet opponents of the AMA’s call to action now have a powerful tool thanks to the APA: the DSM-V.

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[1] The APA working group explains, “There was general agreement that “dependence” as a label for compulsive, out-of-control drug use has been problematic. It has been confusing to physicians and has resulted in patients with normal tolerance and withdrawal being labeled as “addicts.” This has also resulted in patients suffering from severe pain having adequate doses of opioids withheld because of fear of producing “addiction.” Accordingly, the word “dependence” is now limited to physiological dependence, which is a normal response to repeated doses of many medications including beta-blockers, antidepressants, opioids, anti-anxiety agents and other drugs.” One blog commenter notes the need for a new word entirely: “I really like the term ‘allergy’ because it helps people understand better that there are some human beings that have a different biological response (a ‘more!’ response) to substances than other people do.”