By William Brown, Certified Medical Cannabis Specialist

We often hear the terms dependence and addiction when people talk about Cannabis use. But these words often come with preconceived notions that can cloud our understanding. Misconceptions can muddy the waters for those seeking to understand Cannabis as medicine. This article looks closely at the scientific definitions, their relevance to Cannabis, and why addressing this distinction is vital for reducing stigma, promoting evidence-based medical practices, and developing effective harm-reduction strategies.

Addiction and Dependence Are Terms Often Used Interchangeably.

Defining Addiction

Addiction is a chronic behavioral condition marked by the compulsive use of substances despite harmful consequences. It involves significant changes in brain reward circuits (1), particularly those mediated by dopamine, which reinforce the drive to use substances and impair self-control. Over time, these changes result in intense cravings and an inability to regulate usage, even when it leads to serious personal, social, or health-related problems.

Key Characteristics of Addiction:

• Compulsive substance use.
• Cravings are driven by dysregulation of the dopamine system.
• Persistent use despite awareness of negative outcomes.
• Commonly associated with substances like alcohol, nicotine, opioids, and, to a lesser extent, Cannabis.

Understanding Dependence

Dependence refers to the body's physical adaptation to a substance, which manifests as tolerance and withdrawal symptoms. It occurs when the brain adjusts to regular substance use, requiring higher doses to achieve the same effect (tolerance) and causing physical or psychological symptoms when the substance is reduced or stopped (withdrawal).
Unlike addiction, dependence does not necessarily involve the compulsive behaviors or loss of control characteristic of addiction. For instance, a person taking prescribed antidepressants or insulin may become dependent without exhibiting addictive behaviors. (2)

Key Characteristics of Dependence:

• Physical adaptation to a substance.
• Withdrawal symptoms upon cessation (e.g., irritability, insomnia, reduced appetite for Cannabis).
• Can occur without the psychological or behavioral components of addiction.

Cannabis: Dependence vs. Addiction 

When discussing Cannabis, again, the terms dependence and addiction are often used interchangeably but now fall under the label “ Cannabis Use Disorder” in the current Diagnostic and Statistical Manual (DSM). The DSM provides specific diagnostic criteria for mental disorders, as well as a series of codes that allow doctors to summarize often complex conditions for clinical research and insurance purposes. (3)

Awareness of the distinct experiences of each is fundamental for understanding, identification, and harm reduction. Clarity is certainly needed to further conversations about the benefits and challenges of Cannabis in both medical and recreational contexts regarding these distinctions for the individual, and what that may mean based on the DSM.

Substance dependence and substance abuse (addiction) used to be classified as separate health conditions in the DSM, which is the leading manual for diagnosing mental health conditions. This was until the most recent update to the manual in 2013.

The DSM-5 (current version)  has now included both conditions under the umbrella term of substance use disorder, which further adds to the issues of clarity, understanding, and identification. (4) 

Further Reading for Context

Before continuing, here are a few resources to gain a clearer picture of substance use disorders:

• American Psychiatric Association: Substance Use Disorders (5)
• Journal Article: DSM-5 and Addiction Classification (6)
• Verywell Mind: What is the DSM? (7)
• Substance Dependence: Symptoms, Causes, and Treatment (8)
   

Cannabis Use and The Potential For Dependence and Addiction?

While not everyone who uses Cannabis develops addiction (CUD), daily and heavy THC use increases the likelihood of dependence. This probability is from the viewpoint of what has been stated above under the authority of the DSM.

Dependence Potential:

Daily and prolonged Cannabis (THC) use can lead to dependence. 

Withdrawal symptoms include:

• Irritability
• Insomnia
• Reduced appetite
• Anxiety or mood swings

These symptoms are generally milder compared to substances like alcohol, nicotine, or opioids, making Cannabis dependence less physically debilitating but still possibly significant.

Addiction Potential:

Cannabis is considered less addictive than substances like alcohol, nicotine, or opioids. Around 9-10% of users (similar to coffee and chocolate) may develop a Cannabis Use Disorder (CUD) or a “Cannabis Addiction” based on the definitions outlined above. This rate is relatively low compared to addiction rates for alcohol (~15%) or nicotine (~32%), and unlike opioids, Cannabis typically does not induce severe cravings or compulsive behaviors, though psychological dependence can still occur.

Brain Mechanisms: Addiction vs. Dependence

Addiction and dependence involve distinct yet overlapping brain mechanisms (9):

Addiction: 

• Driven by changes in the brain's reward and motivation systems.
• Dopamine circuits in the ventral tegmental area (VTA) and nucleus accumbens are overstimulated, reinforcing compulsive behaviors.
• Involves prefrontal cortex impairments, leading to poor decision-making and loss of control.  

Dependence:

• Primarily involves physical adaptations in the thalamus and basal ganglia.
• Tolerance develops as the brain reduces its natural production of certain neurotransmitters in response to substance use.
• Withdrawal symptoms arise when substance use stops, disrupting the brain's chemical balance.

The Three Stages of Addiction

Addiction unfolds in three primary stages (10), as outlined by modern neurobiological research:

1. Binge/Intoxication:

• Increased dopamine and opioid activity lead to immediate euphoria and habit formation.
• The brain learns to associate the substance with pleasure and reinforces repeated use.

2. Withdrawal/Negative Affect:

• During withdrawal, the brain's reward system is weakened.
• Stress chemicals (e.g., cortisol) are activated, leading to negative emotions and discomfort.

3. Preoccupation/Anticipation:

• Cravings emerge as a result of disruptions in brain areas responsible for self-regulation (e.g., the prefrontal cortex).
• Individuals experience heightened impulsivity and difficulty resisting the urge to use.

Genetic and environmental factors, along with molecular changes in these circuits, significantly influence addiction risk, persistence, and relapse.

Comparing Cannabis to Other Substances

Dependence:

• Cannabis dependence resembles caffeine dependence, with mild withdrawal symptoms and limited impact on physical health.
• Substances like alcohol or opioids cause more severe physical withdrawal, including tremors, seizures, or life-threatening symptoms.

Addiction:

• While Cannabis addiction is less common than nicotine or alcohol addiction, it can still cause significant psychological distress and interfere with daily life for some users.
• Unlike opioids, Cannabis typically lacks intense cravings or life-threatening withdrawal symptoms.

Key Takeaways

Addiction vs. Dependence:

• Addiction is a long-term behavioral condition involving compulsive use, driven by changes in brain reward pathways (e.g., dopamine circuits).
• Dependence is the body’s physiological adaptation, resulting in tolerance and withdrawal, but it does not necessarily involve compulsive use.

Cannabis-Specific Risks:

• Cannabis dependence is relatively common with heavy use but usually involves mild withdrawal symptoms.
• Cannabis addiction (CUD) affects a smaller percentage of users (~9-10%) and is characterized by psychological dependence and difficulty controlling use.

Neurobiology:

• Addiction and dependence affect different brain regions: reward systems (addiction) versus physical regulation centers (dependence).
• Both involve tolerance and withdrawal but differ in behavioral and motivational impacts.

Concluding Thoughts

In doing research for this piece, I have come to a greater understanding of the misunderstanding of these words individually and the use of both to mean the same thing by medical professionals and the misinformed equally.

Recognizing the nuanced differences between addiction and dependence is critical for addressing and understanding substance use issues effectively with care and concern. While Cannabis poses lower risks than substances like alcohol, opioids, or nicotine, its potential for dependence and addiction (abuse) should not be overlooked, no matter how minute.

This has been a very frustrating dive, so I hope this article provides a bit of clarity on something so confusing.

References:

1. Koob, George F, and Nora D Volkow. “Neurobiology of addiction: a neurocircuitry analysis.” The lancet. Psychiatry vol. 3,8 (2016): 760-773. doi:10.1016/S2215-0366(16)00104-8.

2. Donofrio, Justin. “Opioids: Understanding Addiction versus Dependence.” Hospital for Special Surgery, 5 July 2023, www.hss.edu/conditions_understanding-addiction-versus-dependence.asp.

3. Hayes, Alexandra et al. “The Neurobiology of Substance Use and Addiction: Evidence from Neuroimaging and Relevance to Treatment.” BJPsych Advances 26.6 (2020): 367–378. Web.

4. “Psychiatry.” Https://Www.Psychiatry.Org/, www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Substance-Use-Disorder.pdf. Accessed 6 Jan. 2025. 

5. “What Is a Substance Use Disorder?” Psychiatry.Org - What Is a Substance Use Disorder?, www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder. Accessed 5 Jan. 2025.

6. Deborah S. Hasin, Ph.D., et al. “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale.” American Journal of Psychiatry, 1 Aug. 2013, psychiatryonline.org/doi/10.1176/appi.ajp.2013.12060782.

7.  Fritscher, Lisa. “Can the Diagnostic Manual for Mental Health Do More Harm than Good?” Verywell Mind, Verywell Mind, 17 Jan. 2023, www.verywellmind.com/dsm-friend-or-foe-2671930. 

8.  Gupta, Sanjana. “What Is Substance Dependence?” Verywell Mind, Verywell Mind, 10 Oct. 2024, www.verywellmind.com/what-is-substance-dependence-symptoms-causes-treatment-6281698.

9. West Hollywood ATC Editorial Team. “Addiction and the Brain: 10 Parts of the Brain Affected by Addiction.” West Hollywood Addiction Treatment Center, 25 July 2024, https://westhollywoodatc.com/addiction/brain/.

10. “The Addiction Cycle: What Are the Stages of Addiction?” American Addiction Centers, 17 Dec. 2024, americanaddictioncenters.org/the-addiction-cycle. 

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About William Brown:

William owns and operates WbC Therapeutics, a company based on the therapeutic application of Cannabis as medicine. He is also a patient and authorized caregiver in his state. William is a certified Cannabis educator and coach.

Contact William at WbC Therapeutics through the e-mail link below to learn more about his services.

Effective Cannabis Newsletter is a platform to educate on the vital role of the Endocannabinoid System (ECS) in one's health. The information is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. All content, including text, graphics, images, and information, contained in or available through this newsletter is for general information purposes only. It is not medical advice; it is health awareness.