Delta-9-Tetrahydrocannabinol (Delta-9-THC), the primary psychoactive component in cannabis sativa, marks cannabis as one of the most commonly misused illicit substances in the United States. Various parts of the cannabis plant—buds, stems, seeds, and leaves—contain Delta-9-THC, with the highest concentration found in the buds (National Institute of Drug Abuse, 2014). Typically, cannabis is consumed through inhalation of smoke or vapor, or by oral ingestion. It’s often dried and smoked in pipes, hand-rolled cigarettes (joints), or blunts. Vaporizing involves inhaling steam from heated plant matter. Edibles, such as brownies, cookies, and gummy candies infused with Delta-9 THC, are also popular. Hashish, a resinous oil, can be added to edibles as well.
Cannabis use can lead to both reward and dependence, with withdrawal symptoms appearing upon cessation. Regular cannabis consumption can result in varying degrees of impairment. While often referred to as cannabis, the key active ingredient is Delta-9-THC (American Psychiatric Association, 2013). Within user subcultures, cannabis use is often normalized and its potential problems are downplayed or rationalized.
Cannabis has a strong affinity for CB1 receptors in the central nervous system, particularly in the frontal cortices and thalamus. This interaction with CB1 receptors is responsible for the psychoactive effects of cannabis (Lazenka, 2014).
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Diagnostic Criteria for Cannabis Use Disorder (305.20)
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) outlines the criteria for diagnosing Cannabis Use Disorder, coded as 305.20. Diagnosis requires meeting specific criteria within a 12-month period:
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Problematic Pattern of Cannabis Use: A pattern of cannabis use leading to clinically significant impairment or distress, manifested by at least two of the following criteria, occurring within a 12-month period:
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Loss of Control: Cannabis is used in larger amounts or over a longer period than was intended.
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Unsuccessful Attempts to Quit: Persistent desire or unsuccessful efforts to cut down or control cannabis use.
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Excessive Time Spent: A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
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Craving: Craving, or a strong desire or urge to use cannabis. This can include intrusive thoughts, vivid imagery, dreams about cannabis, or even olfactory hallucinations related to cannabis due to preoccupation.
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Continued Use Despite Consequences: Continued cannabis use despite knowledge of having persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by cannabis use. This can include ignoring negative consequences such as legal issues, relationship problems, or decreased work productivity.
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Sacrificing Important Activities: Important social, occupational, or recreational activities are given up or reduced because of cannabis use. This can include neglecting work, school, personal hygiene, or family and friend responsibilities.
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Hazardous Use: Recurrent cannabis use in situations in which it is physically hazardous. Examples include using cannabis before or while operating machinery or driving a vehicle.
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Continued Use Despite Physical/Psychological Problems: Use is continued despite awareness of persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by cannabis. Examples include persistent cough, lack of energy (anergia), or lack of motivation (amotivation).
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Tolerance: Tolerance, as defined by either:
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. -
Withdrawal: Withdrawal, manifested by either:
a. The characteristic cannabis withdrawal syndrome.
b. Cannabis (or a closely related substance, such as a synthetic cannabinoid) is taken to relieve or avoid withdrawal symptoms.
Specifiers for Cannabis Use Disorder (305.20):
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Remission:
- Early Remission: No criteria for Cannabis Use Disorder are met for at least 3 months but for less than 12 months.
- Sustained Remission: No criteria for Cannabis Use Disorder are met at any time during a period of 12 months or longer.
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Controlled Environment: This specifier is used if the individual is in an environment where access to cannabis is restricted (e.g., correctional facility, closely monitored treatment setting).
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Severity: The severity of Cannabis Use Disorder is determined by the number of criteria met:
- Mild: 2–3 symptoms
- Moderate: 4–5 symptoms
- Severe: 6 or more symptoms (American Psychiatric Association, 2013).
Risk Factors Associated with Diagnosis Code 305.20
The DSM-5 identifies several risk factors for developing Cannabis Use Disorder. These include a family history of substance use disorders and a personal history of Conduct Disorder or Antisocial Personality Disorder. Additional risk factors mentioned are lower socioeconomic status (SES), a history of tobacco smoking, unstable or abusive family environments, family members who use cannabis, and poor academic performance (American Psychiatric Association, 2013). It’s important to note that these factors may be correlational rather than directly causal. The DSM-5 also acknowledges that easy access to cannabis is a risk factor for individuals predisposed to use it (American Psychiatric Association, 2013). Furthermore, societal norms that are tolerant of drug use can also be a significant risk factor, as social conformity powerfully influences behavior.
Onset and Development of Cannabis Use Disorder
The onset of Cannabis Use Disorder typically occurs in early adolescence or young adulthood, as noted in the DSM-5 (American Psychiatric Association, 2013).
Differential Diagnosis for Cannabis Use Disorder (305.20)
It’s crucial to differentiate Cannabis Use Disorder from other conditions that may present with similar symptoms. For instance, depression can manifest with symptoms like low energy (anergia), lack of motivation (amotivation), short-term memory issues, and concentration difficulties. In adolescents or young adults, these symptoms could be mistakenly attributed solely to cannabis use, especially if the individual downplays or denies their cannabis use. To accurately diagnose Cannabis Use Disorder and rule out other potential conditions, urine drug testing using enzyme immunoassay to detect cannabinoid metabolites can be employed. The presence of metabolites indicates recent cannabis use, and quantitative testing can measure metabolite levels, providing an estimate of recent cannabis consumption.
Comorbidity and Long-Term Health Risks
Cannabis Use Disorder is associated with several long-term health risks. Smoking cannabis, like smoking tobacco, involves inhaling harmful byproducts of burning plant material. Smoking cannabis can contribute to:
- Respiratory System Issues: Chronic Obstructive Pulmonary Disease (COPD), chronic upper respiratory tract inflammation, bronchitis, and damage to cilia, increasing susceptibility to respiratory infections like rhinovirus and influenza.
- Cardiovascular System Problems: Elevated heart rate and blood pressure, posing risks for individuals with pre-existing heart conditions.
- Reproductive System Effects: Various impacts on both male and female reproductive systems, although the full clinical significance is still under investigation.
- Increased Cancer Risk: Potentially increased risk of cancers of the lungs, oral cavity, esophagus, and related structures (California Society for Addiction Medicine, 2011).
Treatment Options for Cannabis Use Disorder (305.20)
While the DSM-5 doesn’t specify particular treatment modalities for Cannabis Use Disorder (American Psychiatric Association, 2013), effective treatments are available. Individual or group therapy, particularly using Rational Emotive Behavior Therapy (REBT) (Albert Ellis Institute, 2014), has proven helpful. Psycho-education, self-help groups, and lifestyle modifications are also important components of treatment. REBT assists individuals in identifying and changing dysfunctional thought patterns, developing adaptive thinking, and learning to manage emotions without relying on cannabis. Psycho-education challenges common misconceptions about cannabis and provides evidence-based information about addiction. Self-help groups, like 12-step programs, offer crucial support, accountability, and motivation for recovery, facilitating healthier social connections and relationships.
A crucial aspect of recovery is changing social associations, moving away from individuals who actively use substances and building relationships with sober, responsible, and goal-oriented people who can provide positive role models, encouragement, and social support for abstinence.
Prognosis and Outcomes for Diagnosis Code 305.20
For many individuals, cannabis use may remain at a mild level, primarily occurring during adolescence and early adulthood. As individuals mature and face evolving internal and external expectations, their priorities often shift. By their late twenties, many have completed their education, started careers, and begun families. These responsibilities often outweigh the perceived rewards of cannabis use, leading to either cessation or reduction to sub-clinical levels with minimal functional impact.
However, for others, cannabis use can persist at heavy levels, with continued adherence to subcultural norms that rationalize and justify use. Long-term heavy cannabis use is associated with amotivational syndrome, characterized by a gradual decline into apathy, indifference, and lack of motivation. Unlike substances like heroin or crack cocaine which can rapidly lead to life disruption, the effects of cannabis can be more subtle and insidious. Goals may be unmet, responsibilities neglected, and overall quality of life diminished, preventing individuals from reaching their full potential.
For individuals who engage in treatment, the prognosis for recovery from Cannabis Use Disorder is generally positive. While some recognize the negative impact of their cannabis use on their goals but struggle to stop independently, many enter treatment due to external pressures from the legal system or family. A significant challenge in treatment can be helping individuals recognize that their cannabis use is problematic. Cultural acceptance of cannabis, misinformation, and the apathy induced by cannabis itself can hinder motivation to quit.
References
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/
