Which came first: Cannabis use or deficits in impulse control?
Introduction
While the word impulsive has a straightforward enough definition according to the Cambridge dictionary, “acting or done suddenly without any planning or consideration of the results,” there is far less clarity when it comes to describing the psychological term impulsivity (Press, 2008). Impulsivity is a multidimensional construct with separable domains. Consequently, a number of definitions and theoretical conceptualizations have been proposed (Bakhshani, 2014; Stahl et al., 2014; MacKillop et al., 2016; Lee et al., 2019). Despite an overall lack of consensus on the definition, impulsivity is a hallmark for numerous impulse control disorders (e.g. intermittent explosive disorder, oppositional defiant disorder, and klepto- and pyromanias) in addition to serving as a diagnostic criterion for other mental disorders like attention-deficit/hyperactivity disorder (ADHD) and antisocial and borderline personality disorders. Central to this review, there are high rates of co-occurrence between impulse control disorders and substance use disorders (SUDs) (Fontenelle et al., 2011). Indeed, it is often repeated that a hallmark of SUDs is an inability to control the impulse to use drugs even in the face of severe negative consequences.
As with other abused drugs, most individuals who try cannabis will not transition to daily drug use or abuse. Public perception is growing more favorable towards cannabis use (Pacek et al., 2015; Carliner et al., 2017), but for a subset of people chronic use can have severe negative psychological and physical consequences including addiction. Cannabis is one of the three most frequently used drugs of abuse in the United States (US) along with alcohol and tobacco/nicotine (SAMHSA, 2019). Two common misconceptions are that cannabis lacks addiction liability, and that cannabis use disorder (CUD) is rare compared to other SUDs. In recent years, there has been a significant increase in the numbers of young adults showing patterns of frequent use in the US (SAMHSA, 2019). In the last 10 years, the percentage of delta-9-tetrahydrocannabinol (THC, the primary psychoactive chemical in cannabis) in seized cannabis has nearly doubled (Chandra et al., 2019). Correspondingly, there has been an increase in the incidence of CUD measured across multiple studies (Hasin, 2018). Current estimates from US national data place the incidence of meeting diagnostic criteria for CUD at approximately 20% of lifetime users illustrating that it is not a rare phenomenon (Hasin, 2018).
There are many theories about why some individuals develop SUDs and others do not. Drug access represents a primary risk factor (Gillespie et al., 2009). The changing legislative landscape in the US and beyond suggests that cannabis availability will only increase in the coming years. Beyond availability, this review explores one potential explanation for individual differences in susceptibility to cannabis misuse/CUD by examining the relationship with impulsivity. Research in animal models indicates that high impulsivity is correlated with substance abuse susceptibility (Jentsch et al., 2014). Moreover, clinical research suggests that impulsivity levels can influence treatment response and relapse (Loree et al., 2015; Bentzley et al., 2016). Most of this research has centered on alcohol and stimulant use, and indeed strong associations have been described in terms of these abused substances (Perry and Carroll, 2008; Dick et al., 2010). The development of CUD, as for other SUDs, is associated with a constellation of risk factors, but the link between impulsivity and cannabis use warrants further investigation.
Section snippets
Cannabis use disorder
The most recent version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the currently accepted diagnostic criteria for CUD nested under the category of “Substance-related and addictive disorders.” The DSM-5 definition of CUD is “a problematic pattern of cannabis use leading to clinically significant impairment or distress” as manifested by fulfilling 2 or more of the 11 established criteria in a 12 month span (APA, 2013). An unweighted criteria count
Defining the constructs of impulsivity
Despite over a century of research, there is still no unified framework nor agreed upon psychological definition for impulsivity. Numerous personality theories have included the concept of impulsivity (Eysenck and Eysenck, 1977; Cloninger et al., 1993; Zuckerman and Kuhlman, 2000). In this review, we propose that impulsivity can be measured as a trait or a state. Impulsive trait is relatively stable across time, but impulsive state is characterized by variability in impulsivity levels that
The neuroanatomy of impulsivity
The prefrontal cortex (PFC) is the brain structure most often associated with behavioral inhibition and decision making and consequently implicated in impulsivity (Kim and Lee, 2011). The PFC is divided into numerous subregions each with their own functional specializations and embedded within a larger network structure. Most studies describe negative relationships between cortical (and subcortical) gray matter volume and survey measures of impulsivity (Kumari et al., 2009; Matsuo et al., 2009;
Trait impulsivity and cannabinoid use
Trait impulsivity is consistently implicated as a risk factor for both cannabis use and cannabis-related problems (Bidwell et al., 2013; Day et al., 2013; Lopez-Vergara et al., 2019). Certain impulsive personality traits are evident in early development. Indeed, longitudinal cohort studies have demonstrated that temperamental qualities observed as early as three years of age predict personality traits and psychiatric diagnoses later in development (Caspi et al., 1996; Caspi, 2000). Within this
Conclusions
Trait impulsivity has predictive value for cannabis use outcomes. Trait impulsivity may influence some of the subjective effects of acute cannabis (van Wel et al., 2015). This is important because subjective effects in response to cannabis have noted association with use patterns and dependence (Zeiger et al., 2010). The same might be true for behavioral impulsivity, but there is currently a lack of longitudinal data to fully support that notion. In cross-sectional studies, cannabis
Future directions
In brief, we highlight here a few additional related areas for future research. First, there is burgeoning data related to epigenetic mechanisms and transgenerational transmission associated with cannabis use (Szutorisz and Hurd, 2018). Epigenetic modifications brought about by cannabis use can contribute to enduring changes in gene expression and behavior. Few studies have specifically examined the transgenerational relationship between cannabis use and impulsivity, but available studies argue
Funding
This work was supported by the National Institutes of Health [DA041462] to SS.
Declaration of Competing Interest
None.
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