> Table of Contents > Marijuana (Cannabis) Use Disorder
Marijuana (Cannabis) Use Disorder
Kara C. Farley, MD
Dustin K. Smith, DO
image BASICS
DESCRIPTION
Marijuana or cannabis use disorder is classified in DSM-5 in different categories (mild, moderate, or severe) depending on how many symptoms are present. Mild: 2 to 3; Moderate: 4 to 5; Severe: 6+ (1). The definition is used leading to clinically significant impairment or distress, manifested by two or more of the following symptoms within a 12-month period:
  • Taken in larger amounts and over a longer period of time than intended
  • Persistent desire or unsuccessful efforts to cut down or control amount used
  • A great deal of time spent in activities is necessary to obtain, use, or recover.
  • Presence of craving for the substance
  • Recurrent use resulting in failure to fulfill major role obligations at work, school, or home
  • Continued use despite having persistent or recurrent social or interpersonal problems due to cannabis use
  • Important social, occupational, or recreational activities are given up or reduced.
  • Recurrent use in physically hazardous situations
  • Use is continued despite knowledge of having a persistent physical or psychological problem caused or exacerbated by cannabis.
  • Tolerance, defined by using increased amounts of cannabis to achieve the desired effect or intoxication or diminished effect with continued use of the same amount of cannabis
  • Withdrawal
EPIDEMIOLOGY
  • The United States is ranked first among 17 European and North American countries by the World Health Organization for prevalence of marijuana use.
  • Cannabis is the most widely used illicit psychoactive substance in the United States (2).
  • ˜42% of teens will have tried marijuana by the time they graduate from high school.
  • Approximately 30% of students report having used marijuana at college entry (3).
  • In the United States, 10% of those who ever used marijuana become daily users, and 20-30% became weekly users.
  • In the United States, some states have approved medical marijuana use, and two states (Washington and Colorado) have approved recreational use of marijuana.
  • Other states in the United States are currently trying to pass legislation to legalize the use of recreational marijuana.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Main active ingredient in marijuana: delta-9-tetrahydrocannabinol (THC)
  • When marijuana is smoked, THC rapidly passes from the lungs into the blood and to the brain, where it binds to cannabinoid receptors (CBRs).
  • CBRs are responsible for memory, thinking, concentration, sensory and time perception, pleasure, movement, and coordination.
  • THC artificially stimulates the CBRs, disrupting the function of endogenous cannabinoids. A marijuana “high” results from overstimulation of these receptors.
  • Over time, overstimulation alters the function of CBRs, which can lead to addiction and to withdrawal symptoms when drug use stops.
  • Effects of smoked marijuana occur within minutes and can last 1 to 3 hours.
  • Effects from marijuana consumed in foods or beverages appear later, usually in 30 minutes to 1 hour but can last up to 4 hours.
  • Smoking marijuana delivers significantly more THC into the bloodstream than eating or drinking the drug.
RISK FACTORS
  • Age (highest use among those 18 to 25 years)
  • Male sex
  • Comorbid psychiatric disorders (i.e., bipolar disorder, posttraumatic stress disorder [PTSD])
  • Other substance use (i.e., alcohol, cocaine)
  • Lower educational achievement (rates of dependence is lowest among college graduates)
image DIAGNOSIS
  • Screen for marijuana use along with other lifestyle questions such as tobacco and alcohol use.
  • Ask for frequency and amount used (e.g., “How long does a nickel bag last you?”).
  • Unexplained deterioration in school or work performance may be a red flag for abuse.
  • Problems with, or changes in, social relationships (e.g., spending more time alone or with persons suspected of using drugs) and recreational activities (e.g., giving up activities that were once pleasurable) may indicate abuse.
  • If available, information from concerned parents or spouses should be obtained.
PHYSICAL EXAM
  • Evaluate for:
    • Conjunctival injection
    • Xerostomia
    • Nystagmus
    • Increased heart rate
    • Altered pulmonary status
    • Altered body temperature
    • Reduced muscle strength
    • Decreased coordination
  • Withdrawal findings include the following:
    • Restlessness/agitation
    • Irritability
    • Tremor
    • Diaphoresis
    • Increased body temperature
DIAGNOSTIC TESTS & INTERPRETATION
Positive urine drug screen; cannabinoids can be detected in urine weeks to months after marijuana use.
image TREATMENT
  • Several methods of behavioral-based interventions:
    • Cognitive-behavioral therapy
    • Motivational interviewing
    • Counseling
    • Contingency management
    • Social network behavior therapy
    • Twelve-step approach
    • Family-oriented therapy
    • Brief intervention
    • Relapse prevention
    • Community reinforcement approach
  • No intervention to date has proved consistently effective for marijuana abuse.
  • Despite this, trials on cognitive-behavioral therapy and contingency management have shown better outcomes in reducing marijuana use and maintaining abstinence (5).
  • Trials also show that addition of a comprehensive parenting training curriculum did not further enhance efficacy (5).
  • With marijuana abuse, most prevalent among patients suffering from other psychiatric disorders, studies indicate that treating the mental health disorder may help reduce marijuana use, particularly among heavy users and those with more chronic mental disorders.
  • Advice to give to patients for management of withdrawal:
    • Gradually reduce amount of marijuana used before cessation.
    • Delay first use of marijuana until later in the day.
    • Consider use of nicotine replacement therapy if planning to stop, separate tobacco use at the same time.
    • Relaxation, distraction
    • Avoid cues and triggers associated with cannabis use.
  • P.635

  • Prescribe short-term analgesia and sedation for withdrawal symptoms, if required.
  • If irritability and restlessness are marked, consider prescribing very-low-dose diazepam for 3 to 4 days.
  • Provide user and family members with information regarding marijuana abuse and withdrawal to increase understanding of the abuse and reduce likelihood of relapse.
  • Withdrawal symptoms peak on day 2 or 3, and most are over by day 7. Sleep and vivid dreams can continue for 2 to 3 weeks.
MEDICATION
  • No effective medication for the treatment of marijuana abuse
  • One study suggested oral THC could be used to abate marijuana withdrawal in individuals who are trying to quit.
  • Another study concluded medications used to treat other drug use disorders, such as buspirone, lithium, and fluoxetine, may have therapeutic benefit.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Monitor cessation of marijuana use with urine tests over several weeks for the inactive metabolite of cannabis (carboxy-THC).
  • Heavy smokers may continue to be positive for marijuana for up to 6 weeks.
PATIENT EDUCATION
To learn more about marijuana abuse, visit the National Institute on Drug Abuse (NIDA) Web site at www.drugabuse.gov. Other NIDA Web sites include the following:
  • https://drugpubs.drugabuse.gov/promotions/back-to-school
  • http://www.drugabuse.gov/drugs-abuse/marijuana
  • https://teens.drugabuse.gov/
REFERENCES
1. American Psychiatric Association. Substancerelated and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm16. Accessed December 2015.
2. Suerken CK, Reboussin BA, Sutfin EL, et al. Prevalence of marijuana use at college entry and risk factors for initiation during freshman year. Addict Behav. 2014;39(1):302-307.
3. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698): 1383-1391.
4. Abayomi O, Adelufosi AO. Psychosocial interventions for cannabis abuse and/or dependence among persons with co-occurring cannabis use and psychotic disorders. Cochrane Database Syst Rev. 2015;(1):CD011488.
5. Stanger C, Ryan SR, Scherer EA, et al. Clinic- and home-based contingency management plus parent training for adolescent cannabis use disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(6):445-453.e2.
Additional Reading
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  • Budney AJ, Vandrey RG, Hughes JR, et al. Oral delta-9-tetrahydrocannabinol suppresses cannabis withdrawal symptoms. Drug Alcohol Depend. 2007;86(1):22-29.
  • Denis C, Lavie E, Fatséas M, et al. Psychotherapeutic interventions for cannabis abuse and/or dependence in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005336.
  • Fergusson DM, Boden JM. Cannabis use and later life outcomes. Addiction. 2008;103(6):969-976.
  • Freeman MJ, Rose DZ, Myers MA, et al. Ischemic stroke after use of the synthetic marijuana “spice.” Neurology. 2013;81(24):2090-2093.
  • Hooper SR, Woolley D, De Bellis MD. Intellectual, neurocognitive, and academic achievement in abstinent adolescents with cannabis use disorder. Psychopharmacology (Berl). 2014;231(8):1467-1477.
  • Hubbard JR, Franco SE, Onaivi ES. Marijuana: medical implications. Am Fam Physician. 1999;60(9):2583-2593.
  • National Institute on Drug Abuse. Research Report Series: Marijuana Abuse. Bethesda, MD: U.S. Department of Health and Human Services and National Institute of Health; 2010.
  • Vandrey R, Haney M. Pharmacotherapy for cannabis dependence: how close are we? CNS Drugs. 2009;23(7):543-553.
  • Winstock AR, Ford C, Witton J. Assessment and management of cannabis use disorders in primary care. BMJ. 2010;340:c1571.
Codes
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ICD10
  • F12.10 Cannabis abuse, uncomplicated
  • F12.20 Cannabis dependence, uncomplicated
  • F12.288 Cannabis dependence with other cannabisinduced disorder
Clinical Pearls
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  • Marijuana abuse may result in poor performance in school or work, legal problems, and arguments with family.
  • Patients with schizophrenia are frequently found to be using marijuana and their use hindering the treatment for schizophrenia. Management of these dual diagnoses is important for the successful treatment of schizophrenia.
  • Patients should be screened for marijuana use and asked about frequency and amount used.
  • Effects of smoked marijuana can last 1 to 3 hours. Effects from foods or beverages containing marijuana appear later, usually in 30 minutes to 1 hour but can last up to 4 hours.
  • Smoking marijuana delivers significantly more THC into the bloodstream than eating or drinking the drug.
  • Acute marijuana intoxication is manifested by conjunctival injection, increased heart rate, euphoria, heightened sensory perception, altered perception of time, increased appetite, poor short-term memory and concentration, and fatigue. Large doses may result in acute psychosis, delusions, or hallucinations.
  • Inquire all patients about their use of marijuana. Changes in values and attitudes have made marijuana use more mainstream, and patients do not consider marijuana a substance of abuse.
  • Withdrawal symptoms include nausea, weight loss, decreased appetite, insomnia, and depressed mood. Peaks on day 2 or 3 and most are over by day 7.
  • Cognitive-behavioral therapy, motivational interviewing, motivational enhancement therapy, and contingency management are four methods of behavioral-based interventions used in the treatment of marijuana abuse.
  • Some recent research finds that adolescents with cannabis use disorder may not be susceptible to THC neuropsychological deficits once they achieve remission from all drugs for at least 30 days.