With more states legalizing recreational cannabis and emerging research on medical marijuana, the number of patients who present in the primary care setting seeking information on cannabis use is likely to rise. A key component of patient education and monitoring is information on cannabis use disorder and other cannabis-related disorders.
Cannabis-Related Clinical Diagnoses
Cannabis use disorder is one of 5 clinical diagnoses related to cannabis use included in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)14:
- Cannabis intoxication
- Cannabis withdrawal
- Cannabis use disorder
- Unspecified cannabis-related disorder
- Other cannabis-induced disorders
Cannabis intoxication includes clinically significant problematic behavioral or psychological changes in the setting of recent cannabis use.14 These symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, and social withdrawal. Within 2 hours of use, an individual with cannabis intoxication also will experience 2 or more physical symptoms: conjunctival injection (red eyes), increased appetite, dry mouth, and tachycardia. For a diagnosis of cannabis intoxication, these symptoms, which can occur with or without perceptual disturbance, cannot be attributable to a medical or psychiatric condition, or other substance use.14
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Cannabis withdrawal describes symptoms experienced after cessation and typically is associated with heavy and prolonged daily use of cannabis for at least a few months. For this diagnosis, within 1 week of cessation individuals must experience 3 or more of the following symptoms: irritability, anger, or aggression; nervousness or anxiety; sleep disturbance (insomnia or disturbing dreams); decreased appetite or weight loss; restlessness; depressed mood; at least 1 physical symptom (fever, chills, headache, sweating, abdominal pain, or tremor). Symptoms must cause clinically significant distress or impairment to social, occupational, or other functioning and are not attributable to a medical or psychiatric condition or other substance use.14
Assessment for cannabis use disorder involves evaluation of patterns of use in the preceding 12 months; use must cause problems in functioning with clinically significant impairment or distress and must be accompanied by at least 2 of the 11 diagnostic criteria outlined in DSM-5 (Table 1).14 Cannabis use disorder occurs in an estimated 10% of total users, increasing to 17% of those who first used cannabis as teenagers, and between 25% to 50% of those who report daily use.15
Table 1. DSM-5 Diagnostic Criteria for Cannabis Use Disorder14
| • Cannabis is taken in larger amounts OR over a longer period than intended |
| • Persistent desire OR unsuccessful efforts to cut down or control use |
| • Significant time is spent in obtaining, using, or recovering from cannabis use |
| • Cravings or a strong desire to use cannabis |
| • Recurrent use that adversely impacts obligations at work, school, or home |
| • Continued use of cannabis despite having persistent/recurrent social or interpersonal problems caused or exacerbated by use |
| • Important social, occupational, or recreational activities are given up or reduced because of cannabis use |
| • Recurrent use of cannabis in situations in which it is physically hazardous |
| • Cannabis use is continued despite knowing a physical or psychological problem is likely to have been caused or exacerbated by cannabis use |
| • The presence of tolerance, defined as the need to use in increased amounts to achieve intoxication and diminished effect with use of the same amount of cannabis |
| • The presence of withdrawal, as evidenced by characteristic symptoms of withdrawal and cannabis use to relieve or avoid withdrawal symptoms |
Approximately 4.8 million people 12 years or older (or 1.8%) had cannabis use disorder in the past year, according to 2019 data from the National Survey on Drug Use and Health.1 This rate has remained relatively stable since 2002 (Figure).
Unspecified cannabis-related disorder is diagnosed when symptoms cause distress or impairment but do not meet full diagnostic criteria for a specific disorder.14 Other cannabis-induced disorders, such as cannabis-induced psychotic, anxiety, or sleep disorders, are diagnosed when intoxication or withdrawal produces symptoms severe enough to warrant independent clinical attention but only occur in relation to cannabis use.14
Several risk factors increase the likelihood that a first-time user will become a chronic user: earlier age of first use, early and rapid progression to frequent use, concurrent use of other psychoactive substances, comorbid psychiatric disorders, stressful life events, a history of trauma, drug use by peers, and social isolation.7,15
Treatment of Cannabis Use Disorder
Treatment of cannabis use disorder and other cannabis-related conditions centers on reducing and eventually stopping cannabis use. There are no FDA-approved treatments for cannabis use disorder although some medications have shown promise in preliminary or small clinical trials.3 Behavioral treatments that have shown promise include cognitive-behavioral therapy, contingency management, and motivational enhancement therapy.3 It is also important to diagnose and treat other comorbid psychiatric disorders, such as anxiety and depression, as well as addiction to other substances, such as alcohol or cocaine.3 Finally, sleep medications may aid in managing sleep problems that may emerge during marijuana withdrawal.3
| Click here for an accompanying article by Dr Kalensky on the pharmacology, physiologic effects, and clinical evidence on the use of cannabis for medical conditions. |
Melissa Kalensky, DNP, APRN, FNP-BC, PMHNP-BC, CNE, is an assistant professor at Rush University College of Nursing in Chicago.
References
1. Substance Abuse and Mental Health Service Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. September 2020. Accessed November 11, 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
3. National Institute on Drug Abuse. Marijuana research report. Revised July 2020. Accessed August 19, 2021. https://www.drugabuse.gov/publications/research-reports/marijuana/letter-director
