Marijuana (Cannabis) Use Disorder

Basics

Description

  • Marijuana use leading to clinically significant impairment or distress, manifested by two or more of the following symptoms within a 12-month period:
    • Consumption of larger amounts over a longer period of time than intended
    • Persistent desire or inability to cut down or control amount used
    • Inordinate amount of time spent in activities is necessary to obtain, use, or recover from use.
    • Presence of craving for cannabis
    • 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
    • Continued use despite knowledge of 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
    • Withdrawal occurs following cessation of prolonged use and has at least three behavioral symptoms such as anxiety, restlessness, depression, irritability, insomnia, odd dreams, or physical symptoms such as tremors and/or decreased appetite.
  • According to DSM-5, marijuana or cannabis use disorder (CUD) is defined as being mild, moderate, or severe depending on how many symptoms are present; mild: 2 to 3; moderate: 4 to 5; severe: ≥6

Epidemiology

  • The WHO ranks the United States as first among 17 European and North American countries for the prevalence of marijuana use.
  • From 2016 to 2020, there was a 4.5 times increase in licensure for medical cannabis with >2.9 million licensures granted in 2020 (1). It is estimated that 4.5 to 7 million persons in the United States met the criteria for CUD annually. There has been an increase from 15% to 32% of cannabis use for symptoms/conditions without a strong evidence base for use (1). Chronic pain remains the most common reason for medical cannabis licensure. 10–30% of lifetime marijuana users met the criteria for CUD; 23% of these individuals met the criteria for severe use.
  • Risk of CUD is highest amongst those who start using marijuana before the age of 18 years.
  • Cannabinoids have potential for harm especially in vulnerable populations such as adolescents and those with psychiatric disorders. Current evidence is insufficient to support routine prescription of cannabinoids for the treatment of psychiatric disorders. There is also a concern regarding long-term effects on cognitive dysfunction and risk for stroke.
  • Approximately 30% of students have used marijuana by the time of college entry. Individuals who use high-potency cannabis are more likely to use cannabis regularly, have cannabis-related problems, use other illicit drugs, and have general anxiety disorder.
  • Many states have legalized marijuana in some form. In 1969, only 12% of people approved of legalizing/decriminalizing marijuana; by 2021, >90% of Americans approved of cannabis for medical use.

Etiology and Pathophysiology

  • The two most known therapeutically active cannabinoids in marijuana are δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD).
  • THC is the psychoactive component responsible for marijuana’s analgesic, antiemetic, and intoxicating properties. THC concentrations in marijuana have risen over the past 20 years from 4% to 12–20%.
  • CBD is the nonpsychoactive component responsible for marijuana’s antianxiety, antidepressant, antipsychotic, antispastic, anticonvulsant, and antineoplastic properties.
  • Strains of cannabis vary, with some being THC rich, some CBD rich, and some THC/CBD balanced.
  • Smoking marijuana results in 25–50% absorption of THC, which rapidly passes into the circulation. The oral bioavailability of THC is much less (3–10%). Effects of smoked marijuana occur within minutes and last several hours; effects from marijuana consumed in foods or beverages appear more slowly, taking 30 minutes to 2 hours to have an effect.
  • Frequent users are likely to experience withdrawal.
  • The role of cannabis for treating chronic pain continues to evolve.
  • Only 5% of those with CUD seek treatment from a health care provider.

Risk Factors

  • Young individuals, especially 18- to 29-year-olds, are at more risk for severe CUD.
  • Cigarette smokers are at higher risk for CUD compared to nonsmokers.
  • Higher potency marijuana use increases risk of CUD and increases severity of symptoms.
  • Frequency of use affects the risk of CUD. Monthly users are at 4-fold increased risk, weekly users are at 8-fold increased risk, and daily users are at 17-fold increased risk for developing CUD.
  • Family history of chemical dependence
  • Comorbid psychiatric disorders (i.e., antisocial personality disorder)
  • Other substance use (i.e., alcohol, tobacco)
  • Lower educational achievement (rates of dependence are lowest among college graduates); low socioeconomic status
  • Ease of acquisition of marijuana
  • Among youths with mood disorders, CUD is a risk marker for nonfatal self harm, all-cause mortality, and death by unintentional overdose and homicide.

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