Marijuana (Cannabis) Use Disorder

Descriptive text is not available for this image BASICS

DESCRIPTION

  • Marijuana use leading to clinically significant impairment or distress, manifested by ≥2 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 based on presenting symptoms; 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 meet the criteria for CUD annually.
  • In the United States, 52.5 million people used cannabis and 19% of Americans used it at least once in 2021. In 2022, 30.7% of 12th graders reported using cannabis in the past year, and 6.3% reported using cannabis daily in the past 30 days(4).
  • Chronic pain remains the most common reason for medical cannabis licensure. 10–30% of lifetime marijuana users meet the criteria for CUD; 23% of these individuals meet the criteria for severe use.
  • In 2020, an estimated 209 million people, or 4.9% of the global population aged 15 to 64 years, used cannabis at least once in the previous year. Of these, 23.8 million people were estimated to have CUD in 2020. CUD is a notable risk factor for the global burden of disease (3).
  • Risk of CUD is highest amongst those who start begin using marijuana before the age of 18.
  • 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 20%. Additionally, high concentration oils and resins are used to increase THC potency.
  • 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.
  • Only 5% of those with CUD seek treatment from a health care provider.

Genetics

Studies have identified specific genetic variants that are associated with an increased risk of developing CUD

RISK FACTORS

  • Individuals 18- to 29-year-olds, are at more risk for severe CUD.
  • 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 at 8-fold and daily users at 17-fold increased risk for developing CUD.
  • Family history of chemical dependence, comorbid psychiatric disorders, other substance use (i.e., alcohol, tobacco). Lower educational achievement (rates of dependence are lowest among college graduates); low socioeconomic status and 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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