iRace, Medical Marijuana, Mental Health, Public Health, Substance Use

Can Cannabis Be Addictive? A Brief Overview of Cannabis Use Disorder

Cannabis, also commonly referred to as marijuana, is often used to treat a variety of chronic physical and mental health conditions, including epilepsy; pain, nausea, and vomiting associated with cancer and/or chemotherapy; loss of appetite/weight associated with HIV/AIDS; glaucoma; post-traumatic stress disorder; and Crohn’s disease. As legalization of cannabis for both medical and recreational purposes across the United States, in conjunction with a lack of consumer education surrounding the associated risks for adverse health outcomes such as psychosis and cannabinoid hyperemesis syndrome (CHS), access to more potent cannabis products increases, which may contribute to more individuals meeting the diagnostic criteria for cannabis use disorder (CUD).¹
In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), CUD is characterized by a “problematic pattern of cannabis use leading to clinically significant impairment or distress” with at least two of the following eleven criteria in a 12-month period:²
1. Cannabis is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.

3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.

4. Craving, or a strong desire or urge to use cannabis.

5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.

7. Important social, occupational, or recreational activities are given up or reduced because of cannabis use.

8. Recurrent cannabis use in situations in which it is physically hazardous.

9. Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.

10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.
b. Markedly diminished effect with continued use of the same amount of cannabis.

11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal).
b. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
Cannabis withdrawal syndrome (CWS), as described in the 11th criterion above, requires the presence of at least 3 of the following symptoms developing within 7 days of reduced cannabis use:²
1. Irritability, anger, or aggression

2. Nervousness or anxiety

3. Sleep disturbance

4. Appetite or weight disturbance

5. Restlessness

6. Depressed mood

7. Somatic symptoms, such as headaches, sweating, nausea, vomiting, or abdominal pain
CUD can be further categorized by severity based on the number of criteria (symptoms) met:²
1. Mild: 2-3 symptoms

2. Moderate: 4-5 symptoms

3. Severe: 6+ symptoms
While many patients experience significant relief from their ailments with few side effects, current estimates indicate that CUD affects approximately 10% of the 193 million cannabis users across the world,³ while another study found that 28.1% of cannabis users in the US met diagnostic criteria for CUD,⁴ with 17% of weekly and 19% of daily cannabis users meeting the diagnostic criteria.³
Although there is currently no FDA-approved pharmacological treatment available for individuals diagnosed with CUD, which often occurs comorbidly with other mental health and/or substance use disorders, current research suggests that the optimal treatment of CUD consists of “psychosocial-based interventions, including cognitive behavioral therapy (CBT), motivational enhancement therapy (MET) and abstinence-based contingency management combined with CBT and MET.”³ While these treatments have proven to be effective in terms of reduction of both frequency and quantity of cannabis consumption, research indicates that abstinence rates tend to decrease after the conclusion of CUD treatment.⁵
Despite the marked increase in prevalence of CUD, both self-reported engagement with CUD treatment and perceived need for CUD treatment have steadily decreased since 2008, especially among younger adults, potentially due to the public’s changing attitude towards cannabis such as increased availability through legalization and decreased perception of the risks associated with frequent and/or heavy cannabis use.⁶ In addition to lack of perceived need for treatment, barriers to CUD treatment can include factors such as lack of access to treatment, lack of awareness of treatment options, difficulty acknowledging the magnitude of the problem, not being ready to quit using, lack of motivation, and stigma surrounding treatment.⁷ Individuals with CUD were more likely to access treatment when they had greater access to information and education, inclusion of cannabis-specific treatment services (as opposed to general substance use disorder treatment), more flexible treatment options such as providers offering telephone visits and/or extended office hours, and assistance with financial barriers such as childcare and travel.⁷

1. Petrilli, K., Ofori, S., Hines, L., Taylor, G., Adams, S., & Freeman, T. P. (2022). Association of cannabis potency with mental ill health and addiction: a systematic review. The lancet. Psychiatry, 9(9), 736–750.

2. American Psychiatric Association. (2022). Substance-Related and Addictive Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

3. Connor, J. P., Stjepanović, D., Le Foll, B., Hoch, E., Budney, A. J., & Hall, W. D. (2021). Cannabis use and cannabis use disorder. Nature reviews. Disease primers, 7(1), 16.

4. Choi, N. G., Marti, C. N., DiNitto, D. M., & Choi, B. Y. (2022). Psychological Distress, Cannabis Use Frequency, and Cannabis Use Disorder Among US Adults in 2020. Journal of psychoactive drugs, 1–11. Advance online publication.

5. Sherman, B. J., & McRae-Clark, A. L. (2016). Treatment of Cannabis Use Disorder: Current Science and Future Outlook. Pharmacotherapy, 36(5), 511–535.

6. Askari, M. S., Keyes, K. M., & Mauro, P. M. (2021). Cannabis use disorder treatment use and perceived treatment need in the United States: Time trends and age differences between 2002 and 2019. Drug and alcohol dependence, 229(Pt A), 109154.

7. Gates, P., Copeland, J., Swift, W., & Martin, G. (2012). Barriers and facilitators to cannabis treatment. Drug and alcohol review, 31(3), 311–319.