Marijuana (Cannabis) Use Disorder



  • 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 is 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, and/or 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 (1)


  • 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 but a decrease in recreational use, with >2.9 million licensures in 2020 (2). It is estimated that 4.5 to 7 million persons in the United States met the criteria for CUD annually (3). There has been an increase from 15% to 31.8% of cannabis use for symptoms/conditions without a strong evidence base for use (2). Chronic pain remains the most common reason for medical cannabis licensure. CUD applies to a subset of marijuana users; 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.
  • Approximately 30% of students have used marijuana by the time of college entry. In the general population of young people, 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.
  • The landscape is changing rapidly. Many states have legalized marijuana in some form. In 1969, only 12% of people approved of legalizing marijuana; by 2021, >90% of Americans agreed that cannabis should be legal for medical purposes.

Etiology and Pathophysiology

  • The two most known therapeutically active cannabinoids in marijuana are δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Although CBD has become much more widely available, it remains prohibited by the FDA.
  • 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.
  • 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 after 30 minutes to 1 hour and can last up to 4 hours.
  • Frequent users are likely to experience withdrawal.
  • Use in men is reported at 3.5% and women 1.7%; females have a faster transition from recreational use to CUD. An emerging area of study involved cannabis-related drug interactions and adverse events, which have been noted to be increasing in frequency.
  • Evidence for the use of cannabis to treat pain remains mixed.

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 increases risk of CUD and increases severity of symptoms.
  • 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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