Cannabis Use Disorder, 305.20, 304.30, 304.30 (ICD-10 CM Multiple codes)
DSM-5 Category: Substance-Related Disorders
Delta-9-THC (Delta-9-TetraHydrocannabinol) is a psychoactive compound contained in the plant cannabis sativa, which is one the most widely abused illicit drugs in the United States. The buds, stems, seeds, and leaves of the cannabis plant all contain varying amounts of Delta-9-THC, (National Institute of Drug Abuse, 2014), with the highest concentrations typically in the bud. The typical methods of administration are inhalation of smoke or steam, or PO administration. All of the parts of the plant can be dried, and smoked in a pipe, hand-rolled cigarette (joint), or a hollowed out cigar (blunt). The plant matter is also exposed to steam, and the steam is inhaled in a method referred to as vaporizing. The plant matter can be taken PO, and is typically baked into brownies or chocolate chip cookies. Gummy candies that contain Delta-9 THC are also consumed. Resinous oil called Hashish, or more commonly, hash, can also be extracted and introduced into baked goods, or butter used in the production of baked goods.
Cannabis use produces reward and dependence, and withdrawal symptoms upon cessation of use. Its regular use can result in varying degrees of impairment. The designation of the drug is typically cannabis, although the active ingredient is Delta-9-THC (American Psychiatric Association, 2013).It’s use is widely accepted by a subculture of users, who do not see the use as problematic, and will rationalize and justify use.
Cannabis has an affinity for CB1 (Cannabinoid Receptors Type 1) receptors, which are located in the central nervous system, specifically in the frontal cortices and the thalamus. The CB1 Binding produces the psychoactive effects of cannabis (Lazenka, 2014).
Symptoms of Cannabis Use Disorder
According to the DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) the criteria for Cannabis Use Disorder is as follows:
- Use of cannabis for at least a one year period, with the presence of at least two of the following symptoms, accompanied by significant impairment of functioning and distress:
- Difficulty containing use of cannabis- the drug is used in larger amounts and over a longer period than intended.
- Repeated failed efforts to discontinue or reduce the amount of cannabis that is used
- An inordinate amount of time is occupied acquiring, using, or recovering from the effects of cannabis.
- Cravings or desires to use cannabis. This can include intrusive thoughts and images, and dreams about cannabis, or olfactory perceptions of the smell of cannabis, due to preoccupation with cannabis.
- Continued use of cannabis despite adverse consequences from its use, such as criminal charges, ultimatums of abandonment from spouse/partner/friends, and poor productivity.
- Other important activities in life, such as work, school, hygiene, and responsibility to family and friends are superseded by the desire to use cannabis.
- Cannabis is used in contexts that are potentially dangerous, such as operating a motor vehicle.
- Use of cannabis continues despite awareness of physical or psychological problems attributed to use- e.g., anergia, amotivation, chronic cough.
- Tolerance to Cannabis, as defined by progressively larger amounts of cannabis are needed to obtain the psychoactive effect experienced when use first commenced, or, noticeably reduced effect of use of the same amount of cannabis
- Withdrawal, defined as the typical withdrawal syndrome associate with cannabis, or cannabis or a similar substance is used to prevent withdrawal symptoms.
The status of the disorder can be further qualified as follows:
- Early remission
- Sustained remission
An additional specifier for the status of the disorder is:
- In a Controlled Environment, e.g. a treatment facility or correctional facility where access to cannabis is limited.
The severity of the disorder is also noted, depending on the number of symptoms noted:
- Mild – Two or Three Symptoms
- Moderate- Four or five symptoms
- Severe- Six or more symptoms (American Psychiatric Association, 2013).
Risk Factors for Cannabis Use Disorder
Risk factors identified in the DSM-5 include: A family history of chemical dependence and a history of Conduct Disorder or Antisocial Personality Disorder are noted as risk factors. Other risk factors are described in the DSM-5 are low SES (Socio-Economic Status), history of tobacco smoking, unstable/abusive family, other family members who smoke cannabis, and poor academic performance.
(American Psychiatric Association, 2013). However, it could be speculated these factors are correlational rather than causal. The DSM-5 also notes that the local ease of access to cannabis is a risk factor, (American Psychiatric Association, 2013) for individuals who are inclined to use cannabis. A drug-tolerant culture as a risk factor for use, as conformity to social norms has been established as a powerful influence on behavior.
Onset of Cannabis Use Disorder
The DSM-5 notes that most users begin in early adolescence or as young adults (American Psychiatric Association, 2013).
Differential Diagnosis in Cannabis Use Disorder
Depression can present with symptoms of anergia, amotivation, short-term memory deficits, and difficulty concentrating. In a young person, who fits the demographic of a cannabis user, parents or others may attribute the symptoms to cannabis use and denial, particularly if the adolescent cannot articulate their feelings. To rule out other disorders, in addition to meeting the diagnostic criteria listed above, diagnosis of use can be determined through enzyme immunoassay testing of a urine sample for cannabinoid metabolites. The presence of metabolites can indicate recent use, and if quantitative testing is done, the levels of metabolites can be measured, indicating the relative amount of cannabis recently used.
Comorbidity of Cannabis Use Disorder
There is a number of long-term health risks associated with Cannabis Use Disorder. Inhaling the smoke from burnt vegetation, whether it is tobacco leaves or cannabis, is harmful. Use of cannabis by smoking can result in long term, comorbid health problems involving:
- The Respiratory system- COPD (Chronic Obstructive Pulmonary Disease), chronic inflammation of the upper respiratory tract, bronchitis, and damage to cilia, which can increase frequency and severity of common upper respiratory infections such as rhinovirus and influenza.
- The Cardiovascular system- elevated heart rate and blood pressure, which can adversely affect individuals with pre-existing heart disease.
- The Reproductive system- multiple effects in both men and women, although the clinical impact is not well understood.
- Increased risk of cancers of the lungs, oral cavity, esophagus, and associated structures.
(California Society for Addiction Medicine, 2011)
Treatment of Cannabis Use Disorder
The DSM-5 does not specify treatment options for Cannabis Use Disorder (American Psychiatric Association, 2013). Cannabis Use Disorder is treatable by individual or group therapy following the REBT (Rational Emotive Behavior Therapy) model, (Albert Ellis Institute, 2014) as well as psycho-education, self –help groups, and lifestyle changes. REBT can assist the recovering user to recognize dysfunctional thought patterns and replace them with adaptive thinking and to recognize, tolerate and manage their emotions, rather than using cannabis for mood management. Psycho-education can challenge fallacious beliefs about cannabis, which can make use perceived as benign, and provide concrete, didactic information about the nature of addiction in general. Self-help or 12-step groups are an important component of recovery to provide support and accountability, and to maintain motivation. They are also a means of changing associations, and developing healthier relationships.
It is widely accepted in the addiction treatment community that changing associations in a critical part of recovery. This refers to no longer associating with those that are actively using substances, and making connections with sober, responsible, goal oriented individuals who can model pro-social behavior, offer encouragement to remain abstinent, express social disapproval for use, and generally support the individual in their recovery, while holding them accountable for their actions.
Prognosis of Cannabis Use Disorder
For many, cannabis use will not exceed the mild form of the disorder, and they will use typically during their teens and early twenties. As an individual ages, expectations for their conduct, both internally and externally dictated, will change. By the late twenties, most young Americans have completed their education, and are embarking on a career, and family of procreation. This entails responsibilities, which will outweigh the reward from cannabis use, and their use will either be discontinued or be reduced to a sub-clinical level in terms of frequency and quantity, with negligible impact on their functioning.
For others, use of cannabis will remain heavy in terms of frequency and quantity, and the subcultural norms justifying and rationalizing use will be embraced. Long-term use of cannabis is associated with an amotivational syndrome. The effects of cannabis are subtle and insidious, unlike other illicit substances. Use of heroin, crack cocaine, or alcohol can rapidly cause life to become unmanageable. There tends to be a lack of obvious and dramatic effects from smoking cannabis, but rather a gradual slide into amotivation, indifference and apathy. Goals will not be met, and new goals will not be established, important day-to-day tasks will not be completed, and responsibilities will be gradually neglected. Overall, quality of life will be impaired, and the individual will not reach their potential.
If an individual embraces treatment, the prognosis is excellent. Some will recognize that their use of cannabis is preventing goal achievement, but are unable to stop on their own due to the intrinsic reward properties of cannabis. Many individuals are coerced into treatment by either the criminal justice system, or family members exerting pressure on them to meet age expected behavior. A major treatment challenge can be convincing someone that his or her use is problematic. The combination of cultural tolerance and acceptability of cannabis, misconceptions and fallacies fueled by abundant misinformation available on line, and among users, and the apathy and indifference inducing effects of the drug itself can make motivation to quit challenging.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.
California Society for Addiction Medicine (2011). The Adverse effects of marijuana (for health care professionals). Retrieved October 28, 2014, from http://www.csam-asam.org/adverse-effects-marijuana-healthcare-professionals
Lazenka, M. (2014). Everything you wanted to know about cannabinoids: Pharmacology of THC. Science 2.0. Retrieved October 30, 2014 from http://www.science20.com/internal_struggle_of_the_mind/blog/everything_you_wanted_to_know_about_cannabinoids_pharmacology_of_thc-138539
National Institute of Drug Abuse. (2014). Drugfacts: marijuana. Retrieved October 28, 2014, from http://www.drugabuse.gov/publications/drugfacts/marijuana
The Albert Ellis Institute, (2014). The Albert Ellis Institute. Retrieved October 30, 2014 from http://albertellis.org/
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