Caffeine Use Disorder

Ulcers, palpitations, anxiety, and insomnia – pour me another cup!

My recent blog was about Cannabis Use Disorder, including the specific criteria that one needs to diagnose it, according to the addiction psychiatrists who have a conservative definition of cannabis addiction (which likely is overly inclusive). These eleven criteria include tolerance, withdrawal, cravings, inability to control use, and use in hazardous circumstances. The mechanics of this definition was spelled out in excruciating detail in my previous blog.

These criteria are how most substance use disorders are officially diagnosed. This is true from alcoholism (or “alcohol use disorder”) to opioid or cocaine addiction.  My contention is that caffeine is about as addictive as cannabis, perhaps a little more so. How can this be tested?

There isn’t really a strict definition yet of “caffeine use disorder” because caffeine is such a widely accepted and consumed drug. The addiction psychiatrists, who drink as much coffee as the rest of us, wouldn’t want to give all of themselves an addiction. One of my previous blogs is about the hypocritical way we divide the world into “good drugs” and “bad drugs”, often with very minor chemical differences involved. The social context is almost everything and…caffeine fuels our society. The addiction psychiatrists have traditionally dealt with this by putting caffeine use disorder in the category of “a condition for further study.”

But what if we apply the criteria for other addictions to caffeine? Grab a mug, and let’s see who’s addicted. I’ll go first.

If you substituted caffeine for cannabis the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), definition of “Caffeine Use Disorder” might look like this:

1. Use of caffeine for at least a one-year period, with the presence of at least two of the following symptoms, accompanied by significant impairment of functioning and distress.

Yes! It’s been like 40 years, so clearly I qualify for “at least a one-year period”.  My functioning is impaired without it—no mental activity whatsoever; I can’t even speak. With it I do have some symptoms of distress: anxiety, nervousness, insomnia, heartburn, and palpitations.

2. Difficulty containing use of caffeine—the drug is used in larger amounts and over a longer period than intended.

Yes—my sleep specialist has been working on this with me for a decade. I have failed to abide by his strong recommendations to stop by noon and to keep it to one to two cups a day. I crave the hypomanic feeling that caffeine gives me.

3. Repeated failed efforts to discontinue or reduce the amount of caffeine that is used.

Yes, unfortunately. I’ve tried to quit and cut down many times. I did manage to hold out for up to an hour or two on several occasions.

4. An inordinate amount of time is occupied acquiring, using, or recovering from the effects of caffeine.

Yes, I can’t do anything in the morning until I’ve had caffeine, so acquiring caffeine is always my first task, no matter if it involves driving to another state or walking through a blizzard. I then spend the rest of the day dealing with heartburn, palpitations, nervousness, and insomnia (and frostbite, if there truly was a blizzard). Typically, I stand by my coffeemaker and watch it brew in the morning, unable to do anything until I have at least half a cup of sludge in hand.

5. Cravings or desires to use caffeine. This can include intrusive thoughts and images, and dreams about caffeine, or olfactory perceptions of the smell of caffeine, due to preoccupation with caffeine.

Cravings for caffeine can be as intense as they were for opioids during the height of my addiction, especially right when I wake up and remember, just as my head starts pounding, that I am out of coffee and need to rush to the store.

6. Continued use of caffeine despite adverse consequences from its use, such as criminal charges, ultimatums of abandonment from spouse/partner/friends, and poor productivity.

My spouse certainly gets tired of hearing me whine about my self-induced heartburn, anxiety, palpitations, and insomnia that I am giving myself with caffeine. It’s difficult to be productive after a full night’s insomnia due to caffeine (which, alas, perpetuates the binge/suffer cycle…as there is no stronger trigger in the world for caffeine than a poor night’s sleep). I have not put “criminal charges” to the test, but shudder at the thought of a world where caffeine is not legal.

7. Other important activities in life, such as work, school, hygiene, and responsibility to family and friends, are superseded by the desire to use caffeine.

Is this a trick question? Getting coffee is an important life activity. If I haven’t had that first cup in the morning, that will supersede all else. For example, if I’m late to see patients in my clinic but the line at Starbucks is moving at a glacial pace, I would always wait, and deal with the complaints, rather than try to go through clinic muzzy headed without caffeine.

8. Caffeine is used in contexts that are potentially dangerous, such as operating a motor vehicle.

After a huge tree flattened our home in 2017 and the police condemned it on-site, I snuck though the police barriers, back into the potentially unstable structure of my former house, to rescue the  cup of coffee I had just prepared. Emotionally, I couldn’t face up to a demolished home without my morning buzz. Also - I routinely spill my scalding coffee onto my lap when driving and swerve out of my lane.

9. Use of caffeine continues despite awareness of physical or psychological problems attributed to use.

I just chomp on acid blockers, beta blockers, anxiety medications, and sleep aids and continue to guzzle away. I am powerless.

10. Tolerance to caffeine, as defined by progressively larger amounts of caffeine needed to obtain the psychoactive effect experienced when use first commenced, or noticeably reduced effect of use of the same amount of caffeine.

I epitomize tolerance. It takes a good stiff cup in the morning just to wake my digestive system up enough to absorb the second cup. I was up to fourteen shots a day, quivering in blissful mania, until my sleep doctor read me the riot act and threatened to cut off my Ambien. I don’t remember drinking nearly as much in high school – like all addictions, it slowly grows.

11. Withdrawal, defined as the typical withdrawal syndrome associated with caffeine, or caffeine or a similar substance is used to prevent withdrawal symptoms.

By ten in the morning, if I don’t get my fix, my head feels like Bigfoot is jumping up and down on it, and I’m so sleepy I feel like I’ve been roofied with barbiturates. The most effective treatment of caffeine withdrawal is…caffeine!

I appear to qualify for all eleven criteria for “caffeine addiction”. I’m sure many of you do. Is there even a category for eleven out of eleven? I feel like I’m channeling Spinal Tap: “It goes to eleven.” Mild, moderate, severe, and hopeless? My soul mate is clearly Honoré de Balzac, who had an epic caffeine addiction, as described in his humorous essay “The Pleasures and Pains of Coffee.”

Imagine how much more dangerous caffeine would be if it were illegal and if the government were trying to stigmatize it like they have tried with cannabis. There would be no quality control, and each cup could be contaminated with fentanyl or pesticides. It would be like drinking caffeinated moonshine. People would have to risk criminal records just to have their morning cup of joe, which they would use anyways, just with more health and legal jeopardy. I know that I would. Teenagers wouldn’t believe us about the dangers. Any studies done on its harms and benefits would have results that skewed toward harm due to the consequences of prohibition. As such, it would seem much more harmful than it is. Does this remind you of anything? (hint: a green leafy psychoactive drug/medicine).

One might ask if it is just a coincidence that the “Arbiters of What Is and Isn’t Addictive” left out coffee. Was it an oversight? Or did just an iota of hypocrisy and self-serving thinking creep in so that they just happened to skip the one substance that most of them are addicted to, that doesn’t contribute to moral panic, and that they can’t bill people $450/hour for treating?

On what grounds is caffeine less addictive than cannabis? Surely not on percentages of people addicted—not even close, as many more people are addicted to caffeine. Not on deadliness: people die from caffeine, such as athletes trying to get a competitive edge, or teens screwing around with energy drinks. We’re still waiting for a direct death from cannabis, as it is impossible to die from overconsumption. If anyone thinks it’s on grounds of cravings or withdrawal, just try getting between me and my coffeemaker first thing in the morning.

Enough of the hypocrisy about caffeine and cannabis!

You can find my books "Seeing Trough The Smoke" here and "Free Refills" here.