Marijuana (Cannabis) Use Disorder

Marijuana (Cannabis) Use Disorder is a topic covered in the 5-Minute Clinical Consult.

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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:
    • 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
    • Inordinate amount of time spent in activities is necessary to obtain, use, or recover from use.
    • 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
    • Withdrawal
  • According to DSM-5, marijuana or cannabis use disorder is classified into different categories (mild, moderate, or severe) depending on how many symptoms are present. Mild: 2 to 3; moderate: 4 to 5; severe: 6+ (1)

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).
  • In 2014, an estimated 22 million Americans, age >12 years, self-identified as current marijuana users
  • Prevalence of marijuana use disorder rose from 1.5% to 2.9% over the last decade.
  • 45% of 12th graders have tried marijuana.
  • Approximately 30% of students have used marijuana at the time of college entry (3).
  • In the United States, 10% of marijuana users become daily users, 20–30% become weekly users.
  • Younger users have a higher rate of addiction; 1 in 6 adolescents become addicted with repeated use.
  • Marijuana use is increasing in pregnant women. In 2002, 2% reported using in the last month. In 2014, 7% of pregnant women aged 18 to 25 years reported use.
  • In the United States, the legal landscape is changing rapidly. 30 states and the District of Columbia have legalized marijuana in some form, whereas eight states and the District of Colombia have legalized recreational marijuana.
  • Popular opinion has changed over time. In 1969, only 12% of people approved of legalizing marijuana. In 2015, 58% approved of legalization.

Etiology and Pathophysiology

  • Currently, there are two well-known therapeutically active cannabinoids in marijuana, δ9-tetrahydrocannabinol (THC) and cannabidiol.
  • THC is responsible for marijuana’s analgesic, antiemetic, and intoxicating properties.
  • Cannabidiol is the nonpsychoactive component responsible for marijuana’s antianxiety, antidepressant, antipsychotic, antispastic, anticonvulsant, and antineoplastic properties.
  • In terms of bioavailability, smoking marijuana results in 25–50% absorption of THC, which rapidly passes into the circulation. When ingested, 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.
  • Cannabinoid receptors (CBRs) are associated with memory, thinking, concentration, sensory/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.
  • With time, overstimulation alters the function of CBRs, leading to addiction and withdrawal.

Risk Factors

  • Family history of chemical dependence including THC
  • 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

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