cannabis-disorderHalf the US population reports having tried cannabis at one time or another. Only a minority of users– perhaps 9-10%– will go on to develop a Cannabis Use Disorder. But that’s a truly immense number. Marijuana already trails only alcohol and tobacco as the most common drug of abuse among those in treatment, and could challenge the leaders in coming years.

The DSM5 criteria for a diagnosis of CUD require a minimum of two of the following:

Taken in larger amounts or over longer period of time than intended. Todd, 26, reports that he’s “smoking more now than I ever did, even in college. I don’t want to be stoned so much, I have a job and a family, and I keep thinking I’ll grow out of it. But… I haven’t.”

Persistent desire or unsuccessful efforts to cut down or control. Mark, 33: “I was spending way too much on pot and pills so I made a resolution to smoke only two days a week. But after six months I realized I hadn’t managed to stick to it even once.”

Great deal of time spent in activities needed to obtain, use, or recover from drug’s effects. Donna, 24, has “all these rituals around smoking. I’m always buying paraphernalia I don’t need — pipes and pretty clips. I’m obsessive about carrying it with me when I travel. Sometimes I forget my toothbrush, but never the dope. And if for some reason I can’t get at it, I’m a nervous wreck.”

Craving or strong desire to use. Dwayne, 31, reports strong, almost continuous craving for cannabis. It’s most intense during the week when he abstains, but even a weekend binge doesn’t get rid of it entirely. Note: if you prefer a validated instrument, the Marijuana Craving Questionnaire (MCQ) is available from Stephen Heishman PhD (you can reach him through his NIH profile page.)

Failure to fulfill major role obligations (work, home, or school). Wanda, 39, works from home doing medical billing for a large healthcare provider. She resolved to put off smoking pot till after lunch, so she could get her work done in the morning. But she rarely made it past 10 a.m., and routinely fell behind in her work.

Continued use despite persistent or recurrent problems (social or interpersonal) caused or aggravated by cannabis use. Bernard, 28, is a city police officer. Department policy strictly prohibits drugs on the job, but he carries small amounts of pot at all times. Once, in the locker room, a baggie fell out of his pocket in full view of another officer, who reported him. Bernard admits that could have happened hundreds of times before. He’d been lucky it hadn’t.

Important social, recreational, or occupational activities given up or reduced due to use. Belinda, 43, runs a busy kitchen in a homeless shelter. She was confronted by her boss about lateness and leaving the job early. She admitted being ‘hungover’ from heavy marijuana use and also to battling strong cravings in the late afternoon.

Recurrent use in situations where physically hazardous. Billy, 54, is a long distance truck driver who has made a science out of passing the periodic drug tests required by his employer. He uses a variety of masking agents or on occasion substitutes someone else’s clean sample. Billy knows the combination of pot and caffeine pills he takes for long trips contributes to the extreme fatigue he sometimes experiences.

Use continues despite knowing a persistent or recurrent physical or psychological problem is caused or aggravated. Maria has been diagnosed as bipolar and placed on a medication regimen. Because of her history, her psychiatrist has advised her to avoid all drugs. She has been able to comply except for marijuana. She wonders if that is why she is not making more progress.

Now, DSM5 may not consider tolerance and dependence along with these symptoms, to be evidence of CUD, but it does acknowledge their influence. By the way, perhaps 20% of users will experience withdrawal– evidence of their dependence on the drug– regardless of whether they have other symptoms.

Tolerance: as evidenced by a need for markedly increased doses to achieve intoxication or desired effect; OR Markedly diminished effects with use of same amount of cannabis.

Withdrawal: as evidenced by the characteristic withdrawal syndrome, OR use of cannabis to relieve or avoid withdrawal symptoms.

Example: Cynthia reports feeling noticeably more anxious and irritable the day after an evening of smoking. She  discovered that more pot relieved the symptoms and reduced her discomfort.

Cannabis withdrawal is considered mild in comparison to drugs such as heroin or alcohol. The most severe symptoms last a few days, others can linger for several weeks. Yet nicotine withdrawal is not considered severe, either, and it’s a serious barrier to motivation to quit tobacco.

Severity of CUD is measured simply by number of symptoms: Mild is 2-3 symptoms, moderate 4-6, and severe 6 or more.

In early remission means that of the above criteria, none (or craving alone) have been evident for a period of three months or longer, but not to exceed more than 12 months.

 Sustained remission means no criteria have been met in the past 12 months.

 In a controlled environment: the remission has been in a restricted setting such as residential treatment or incarceration, where the drug has not been available.

Presumably, someone who is in sustained remission is still vulnerable to a return of the disorder and its symptoms if and when marijuana use is resumed.

Like other drug disorders, CUD may begin in adolescence and develop gradually. The patient may arrive in treatment only after many years of (apparently, in the patient’s view, successful) use. The psychological defenses– denial, rationalizing, externalizing, minimizing, etc.– around use may be comparable to those found with alcoholism. Though the patient may exhibit a desire to change, these defenses may undermine his or her motivation.


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