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🌿 Marijuana (Cannabis) Use Disorder (CUD)

Authors: Jason Edward Lambrecht, MD; Paul G. Millner, MD; Bradley Devrieze, MD

🧾 DEFINITION

Cannabis use leading to clinically significant impairment/distress, defined by β‰₯2 of the following within 12 months (DSM-5 criteria):

  • Larger amounts/longer duration than intended
  • Inability to cut down or control use
  • Excessive time spent obtaining/using/recovering
  • Craving
  • Role failure at work/school/home
  • Continued use despite social/interpersonal problems
  • Reduction in important activities
  • Use in physically hazardous situations
  • Use despite physical/psychological problems
  • Tolerance
  • Withdrawal

🚦Severity (DSM-5):

  • Mild: 2–3 symptoms
  • Moderate: 4–5 symptoms
  • Severe: β‰₯6 symptoms

πŸ“Š EPIDEMIOLOGY

  • 4.5 to 7 million meet CUD criteria annually in the U.S.
  • 10–30% of lifetime users meet criteria for CUD
  • Risk ↑ if use begins <18 years
  • High-potency strains increase dependence

  • 2.9 million medical marijuana licenses in 2020

  • Chronic pain = most common medical use
  • 30% of college entrants have used marijuana

🧬 ETIOLOGY & PATHOPHYSIOLOGY

πŸ§ͺ Cannabinoids:

  • THC (Ξ”9-Tetrahydrocannabinol) = psychoactive (↑ euphoria, appetite, analgesia)
  • CBD (Cannabidiol) = non-psychoactive (anxiolytic, anticonvulsant, antipsychotic)

🚬 Pharmacokinetics:

  • Smoking: 25–50% THC absorption; onset: minutes, lasts hours
  • Oral: 3–10% bioavailability; onset: 30–120 min

⚠️ RISK FACTORS

  • Early onset of use (<18 yrs)
  • High frequency:
  • Monthly: 4Γ— risk
  • Weekly: 8Γ—
  • Daily: 17Γ—
  • High THC potency
  • Comorbid psychiatric disorders (e.g., ASPD)
  • Family hx of addiction
  • Tobacco/alcohol use
  • Low education/SES
  • Mood disorder in youth β†’ ↑ risk of overdose/self-harm

πŸ” DIAGNOSIS

πŸ”Ž SCREENING

  • Ask: frequency, quantity (1/8 oz = ~60 joints)
  • Occasional = 1/8 oz/week; Moderate = 1/4 oz/week; Heavy = 1/2 oz/week
  • Investigate school/work decline, social withdrawal
  • Cross-check with parents or partners if possible

🧠 Symptoms

  • Acute intoxication: euphoria, laughter, time distortion, increased appetite, anxiety/panic/psychosis (high dose)
  • Withdrawal: irritability, insomnia, ↓ appetite, nausea, tremor, restlessness
  • Symptoms peak at day 2–3; resolve by day 7

πŸ§‘β€βš•οΈ PHYSICAL EXAM

  • Conjunctival injection
  • Tachycardia
  • Poor coordination
  • Dry mouth, AMS
  • Withdrawal: tremors, diaphoresis, irritability

πŸ”¬ TESTING

  • Urine Drug Screen (detects up to weeks)
  • Blood: for acute effects
  • Hair testing: unreliable (may reflect passive exposure)
  • Note: Tests confirm use, not CUD

πŸ’Š TREATMENT

🚫 No FDA-approved medications for CUD

βœ… Behavioral Therapies (Mainstay):

  • CBT
  • Motivational Interviewing
  • Contingency Management
  • 12-Step Program
  • Relapse Prevention
  • Community Reinforcement

πŸ§ͺ Experimental/Adjunctive (limited evidence):

Class Agents Evidence
SSRIs Fluoxetine, etc. ❌ No reduction in use
Anxiolytics Buspirone ❌ No benefit over placebo
Antipsychotics Risperidone, etc. ⚠️ Insufficient evidence
Cannabinoid Rx Dronabinol, Nabiximols βœ”οΈ May ease withdrawal
Craving reduction Naltrexone, NAC ❓ Limited/uncertain evidence
Gabapentin ❌ Not helpful

πŸ”„ WITHDRAWAL MANAGEMENT

  • Reduce gradually before quitting
  • Delay first daily use to reduce dependency cycle
  • Diazepam (low-dose, 3–4 days) for severe agitation
  • Address co-use of tobacco
  • Avoid triggers/cues

πŸ“… FOLLOW-UP

  • Urine test: weekly or biweekly
  • Metabolites may stay in urine for up to 6 weeks in chronic users
  • Counseling for family; relapse risk reduction

πŸŽ“ PATIENT EDUCATION

❗ COMPLICATIONS

⏱️ Acute:

  • Panic, paranoia
  • Tachycardia, AMI
  • Psychosis (hallucinations, delusions)
  • Impaired driving β†’ ↑ MVC risk

🧠 Chronic:

  • Cognitive decline
  • Poor educational/work outcomes
  • ↑ Risk of stroke, heart failure, pancreatitis
  • Respiratory issues: chronic bronchitis
  • Cannabinoid Hyperemesis Syndrome
  • ↑ Risk of other addictions (gateway hypothesis)
  • Psychotic disorders in genetically vulnerable

πŸ“œ ICD-10 CODES

  • F12.10: Cannabis abuse, uncomplicated
  • F12.20: Cannabis dependence, uncomplicated
  • F12.288: Cannabis dependence w/ cannabis-induced disorder

πŸ’‘ CLINICAL PEARLS

  • Only 5% of patients with CUD seek treatment
  • THC content has tripled in past 2 decades
  • Monitor students and adolescents for early signs
  • Withdrawal may mimic depression/anxiety
  • Emphasize psychosocial intervention, not pharmacotherapy