Cannabis Intoxication DSM-5 292.89 (F12.12)
DSM-5 Category: Caffeine-Related Disorders
Introduction
Cannabis intoxication refers to the side effects seen as a result of the active ingredient found in cannabis known as delta-9-tetrohydrocannabinol or THC (Crippa, et al., 2012). There are three forms of cannabis which are the flower, resin and the hash oil. The most widely consumed form of cannabis is marijuana, which contains the most amount of THC. Cannabis is the most commonly used illicit drug in the United States as well as globally (Crippa, et al., 2012). While cannabis has previously been taken for illegal recreational purposes, recently the drug has been legalized in many states in the US, for medicinal purposes. Easily obtainable, it mainly comes from the cannabis plant, and is mostly smoked, though it can also be eaten or drank in a tea. Taking cannabis can result in a range of physical and mental issues stemming from increased hunger to psychosis and hallucinations. THC binds to cannabinoid brain receptors. Once these receptors are activated, it interferes with the normal sequence of brain functioning, producing the effects.
Symptoms of Cannabis Intoxication
Symptoms of cannabis intoxication can include acute and chronic effects. These include increased hunger, sleepiness, impaired cognition and perception, disorientation, and even acute psychosis. According to DSM-5, a diagnosis of cannabis intoxication should include recent history of cannabis, exhibiting clinically considerable challenging behavioral or psychological changes, such as euphoria, impaired judgment, and motor skills, which have taken place since cannabis use (American Psychiatric Association, 2013). In addition, there should be at least two of the following, which occur about two hours after using cannabis: Red eyes, dry mouth, increased appetite, tachycardia, as well as symptoms that are not indicative of any other condition, whether medical or a mental disorder.
Differential Diagnosis of Cannabis Intoxication
Cannabis intoxication is similar to intoxication by other kinds of substances (American Psychiatric Association, 2013). The main difference is that with other substances, decreased hunger, nystagmus, ataxia, and increased aggression can be seen. Small doses of hallucinogens and phenyclicidine can produce similar behaviors seen with cannabis intoxication. With phenyclicidine, in addition to these behaviors, the patients usually exhibit violent behavior and ataxia.
Diagnosis of Cannabis Intoxication
One of the main features of cannabis intoxication is that any behavioral or psychological changes should take place while using or right after using cannabis (American Psychiatric Association, 2013). Intoxication usually starts with a period where the patient feels high, along with symptoms that include euphoria, issues with short-term memory, being unable to accomplish mental tasks, lethargy, excessive drowsiness, and impaired judgment. In some cases, severe anxiety can be present, and social withdrawal transpires. Along with these psychoaffective effects, at least two or more of the subsequent signs should be seen two hours using cannabis. These are immense hunger, dry mouth, conjuctival injection/red eye, and tachycardia.
Intoxication occurs in a matter of minutes after smoking cannabis, but can take longer, up to a few hours, if cannabis is consumed by mouth. The effects of cannabis intoxication remain ongoing for about three to four hours when smoked, but intoxication can be longer when cannabis is consumed orally.
There are multiple ways of measuring THC and detecting cannabinoids. These include urine testing, blood testing, hair analysis, and saliva testing. While a urine sample is quick and cheap, it may be difficult during acute intoxication, with a blood test being the preferred option. High levels of THC are normally are found in the blood within three to ten minutes after inhaling cannabis (Armentano, 2013).
Risk Factors for Cannabis Intoxication
The main risk factor for cannabis intoxication is the dose/levels of active ingredient THC found in the consumed form of cannabis. Other risk factors include the method of administration, as well as the uniqueness of the individual using cannabis, like tolerance, absorption rate and sensitivity. Since the active ingredient THC, is fat-soluble like most cannabinoids, the effects of cannabis intoxication can normally carry on or reoccur for twelve to twenty four hours because of the time-consuming release of the psychoactive substances into circulation in the body (Danovitch, 2013).
Risk factors for cannabis use in general should be considered as well. These include behavioral disorders such as childhood conduct disorder and antisocial personality disorder. The use of other substances such as alcohol and history of intoxication with other substances can increase the risk of cannabis use and intoxication.
Treatment of Cannabis Intoxication
Treating cannabis intoxication requires a combination of medical care and consultations (Winstock, Ford, & Witton, 2010). The acute phase of cannabis intoxication usually resolves within four to six hours.
The main aspects of medical care involve constant support and preservation of a non hostile setting, decreased stimuli, having a specific nurse keep the patient calm, and the well thought out use of medications like benzodiazepines to treat anxiety. Using short-term benzodiazepines such as lorazepam are recommended for significant anxiety alone. This is because any cannabis related anxiety should ultimately resolve even without medication. When giving lorazepam, the patient’s vital signs should be adequately monitored, as it can depress all aspects of the Central Nervous System.
After treating the acute phase of cannabis intoxication, it is important that the person gets evaluated by a psychiatrist. Given the huge impact of cannabis intoxication on a person’s psychology and social life, complete abstinence should be the treatment goal (Winstock, Ford, & Witton, 2010). Staging interventions may be required, that involves an inclusive treatment plan. Incorporating lifestyle changes, and identifying any family, personal or esteem issues may assist in this process. The use of therapy, whether one-to-one or group, may be required in treating cannabis intoxication. While most patients do not need hospitalization as a result of cannabis intoxication, in instances when other medical or psychiatric problems are present, this may be necessary.
Comorbidity of Cannabis Intoxication
Other disorders have similar presentations as cannabis intoxication, so it is important to make the differentiation. Two commonly experienced psychiatric issues seen with cannabis intoxication are panic and anxiety attacks, and are jointly known as cannabis-induced anxiety disorder (American Psychiatric Association, 2013). These contribute greatly to the stoppage of the use of cannabis. Frequently seen are acute psychotic episodes, which present with symptoms such as delusions, confusions, hallucinations, hostility, paranoid ideation and labile affect. Normally these symptoms should disappear a week after the cessation of cannabis and intoxication. In some instances, the psychotic episodes may continue for a significant amount of time after the acute experience. Similarities with acute schizophreniform disorders may also be present.
Another commonly seen comorbidity is delirium. It is important to distinguish cannabis intoxication delirium, from that of other substances or a medical condition. The key feature lies in the individual having a recent history of cannabis use, and experiencing a decreased ability of awareness and focus, and well as issues with cognition.
Cannabis-induced sleep disorder can also develop quickly after cannabis intoxication. In some situations, this may last even up to a month, due to acute withdrawal or severe intoxication. Understanding this presentation should be helpful in treating the sleep disturbance.
Cannabis use can affect an individual’s daily functioning, and affect both work and social lives. This is especially true as a result of the impaired mental functioning and motor skills, as well as impacting memory and judgment. An individual with cannabis intoxication may be unable to perform at a higher level, and be out of touch with reality.
Prognosis of Cannabis Intoxication
In most cases, advanced medical care is not needed for regular cannabis intoxication. In some cases, more severe symptoms are seen such as psychosis and suicidal thoughts, which require further treatment or advice. These symptoms are sometimes associated with other random compounds that are mixed in with the form of cannabis. In certain rare cases, cannabis intoxication can lead to comatose conditions in children (Crippa, et al., 2012). This can be fatal, and would require ventilator support. In general, the acute toxicity of cannabinoids is considered to be low. Furthermore, cannabis intoxication has resulted in teenage deaths, by causing brain infarction. There have also been reports of acute myocardial infarction, transitory ischemic attacks, and cardiac arrthymias, all of which can increase a person’s risk of death (Crippa, et al., 2012). In regards to cardiovascular disease, cannabis intoxication can result in higher levels of catecholamines, as well as require the heart to work harder.
Living with Cannabis Intoxication
Cannabis intoxication is not a chronic event. Given its long term effect on an individual’s health, including affecting cardiovascular health, and social implications, it is important to assist individuals with a history of cannabis intoxication. This helps prevent subsequent ones, and helps restore cognitive abilities that can negatively impact both occupational, social and family lives.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Armentano, P. (2013). Should Per Se Limits Be Imposed For Cannabis? Equating Cannabinoid Blood Concentrations with Actual Driver Impairment: Practical Limitations and Concerns. Humboldt Journal of Social Relations(35), 45-55.
Crippa, J., Derenusson, G., Chagas, M., Atakan, Z., Martin-Santos, R., Zuardi, A., & Hallak, J. (2012). Pharmacological interventions in the treatment of the acute effects of cannabis: a systematic review of literature. Harm Reduction Journal, 1-6.
Danovitch, I. (2013). Sorting Through the Science on Marijuana: Facts, Fallacies, and Implications for Legalization. McGeorge Law Review, 43(1), 91-108.
Winstock, A., Ford, C., & Witton, J. (2010, April 10). Assessment and management of cannabis use disorders in primary care. BMJ, 340, 800-804.
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