Cannabis use and disorder: Clinical manifestations, course, assessment, and diagnosis
- David A Gorelick, MD, PhD
David A Gorelick, MD, PhD
- Professor of Psychiatry
- University of Maryland School of Medicine
Cannabis (also called marijuana) is the most commonly used illegal psychoactive substance worldwide . Its psychoactive properties are primarily due to one cannabinoid: delta-9-tetrahydrocannabinol (THC); THC concentration is commonly used as a measure of cannabis potency .
The legal status of cannabis use, for medical as well as recreational purposes, varies internationally as well as across the United States. The potency of cannabis has increased significantly around the world in recent decades, which may have contributed to increased rates of cannabis-related adverse effects. Cannabis use disorder develops in approximately 10 percent of regular cannabis users, and may be associated with cognitive impairment, poor school or work performance, and psychiatric comorbidity such as mood disorders and psychosis.
The clinical manifestations, course, assessment, and diagnosis of cannabis use disorder in adults are reviewed here. The epidemiology and health consequences of cannabis use and cannabis use disorder are reviewed separately. The pathogenesis, pharmacology, and treatment of cannabis use disorder in adults are also reviewed separately. Acute intoxication, from cannabis and synthetic cannabinoids, and cannabis withdrawal are also reviewed separately. (See "Cannabis use and disorder: Epidemiology, comorbidity, health consequences, and medico-legal status" and "Cannabis use and disorder: Pathogenesis and pharmacology" and "Treatment of cannabis use disorder" and "Cannabis (marijuana): Acute intoxication" and "Synthetic cannabinoids: Acute intoxication".)
The defining manifestation of cannabis use disorder is a persisting pattern of cannabis use that results in clinically significant functional impairment in two or more domains within a period of 12 months . Typical manifestations of cannabis use disorder include impairment in school or work function, giving up of previously enjoyed social and recreational activities, and use of cannabis in potentially hazardous situations, eg, while driving.
The differential diagnosis from nonproblematic cannabis use relies on a careful assessment of the presenting problems or impairments, not on the absolute intensity (quantity and frequency) of cannabis use. Key features suggesting the diagnosis of cannabis use disorder include patient denial of cannabis-related problems in the face of reports from reliable collateral sources (eg, family, school, employer) and patient denial of cannabis use in the face of objective evidence to the contrary (eg, urine drug testing).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- United Nations Office on Drugs and Crime, World Drug Report 2016, Vienna 2016.
- Swift W, Wong A, Li KM, et al. Analysis of cannabis seizures in NSW, Australia: cannabis potency and cannabinoid profile. PLoS One 2013; 8:e70052.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Behrendt S, Wittchen HU, Höfler M, et al. Transitions from first substance use to substance use disorders in adolescence: is early onset associated with a rapid escalation? Drug Alcohol Depend 2009; 99:68.
- Hines LA, Morley KI, Strang J, et al. The association between speed of transition from initiation to subsequent use of cannabis and later problematic cannabis use, abuse and dependence. Addiction 2015; 110:1311.
- Perkonigg A, Goodwin RD, Fiedler A, et al. The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 2008; 103:439.
- Hayatbakhsh MR, Najman JM, Bor W, et al. Multiple risk factor model predicting cannabis use and use disorders: a longitudinal study. Am J Drug Alcohol Abuse 2009; 35:399.
- Silins E, Hutchinson D, Swift W, et al. Factors associated with variability and stability of cannabis use in young adulthood. Drug Alcohol Depend 2013; 133:452.
- Wittchen HU, Fröhlich C, Behrendt S, et al. Cannabis use and cannabis use disorders and their relationship to mental disorders: a 10-year prospective-longitudinal community study in adolescents. Drug Alcohol Depend 2007; 88 Suppl 1:S60.
- van der Pol P, Liebregts N, de Graaf R, et al. Predicting the transition from frequent cannabis use to cannabis dependence: a three-year prospective study. Drug Alcohol Depend 2013; 133:352.
- Korhonen T, Huizink AC, Dick DM, et al. Role of individual, peer and family factors in the use of cannabis and other illicit drugs: a longitudinal analysis among Finnish adolescent twins. Drug Alcohol Depend 2008; 97:33.
- Fergusson DM, Boden JM, Horwood LJ. The developmental antecedents of illicit drug use: evidence from a 25-year longitudinal study. Drug Alcohol Depend 2008; 96:165.
- Liebregts N, van der Pol P, Van Laar M, et al. The Role of Study and Work in Cannabis Use and Dependence Trajectories among Young Adult Frequent Cannabis Users. Front Psychiatry 2013; 4:85.
- Turner SD, Spithoff S, Kahan M. Approach to cannabis use disorder in primary care: focus on youth and other high-risk users. Can Fam Physician 2014; 60:801.
- Hjorthøj CR, Hjorthøj AR, Nordentoft M. Validity of Timeline Follow-Back for self-reported use of cannabis and other illicit substances--systematic review and meta-analysis. Addict Behav 2012; 37:225.
- Newton AS, Gokiert R, Mabood N, et al. Instruments to detect alcohol and other drug misuse in the emergency department: a systematic review. Pediatrics 2011; 128:e180.
- Musshoff F, Madea B. Review of biologic matrices (urine, blood, hair) as indicators of recent or ongoing cannabis use. Ther Drug Monit 2006; 28:155.
- Zaldívar Basurto F, García Montes JM, Flores Cubos P, et al. Validity of the self-report on drug use by university students: correspondence between self-reported use and use detected in urine. Psicothema 2009; 21:213.
- Mayet A, Esvan M, Marimoutou C, et al. The accuracy of self-reported data concerning recent cannabis use in the French armed forces. Eur J Public Health 2013; 23:328.
- Garg M, Garrison L, Leeman L, et al. Validity of Self-Reported Drug Use Information Among Pregnant Women. Matern Child Health J 2016; 20:41.
- Milman G, Barnes AJ, Schwope DM, et al. Disposition of cannabinoids in oral fluid after controlled around-the-clock oral THC administration. Clin Chem 2010; 56:1261.
- Macdonald S, Hall W, Roman P, et al. Testing for cannabis in the work-place: a review of the evidence. Addiction 2010; 105:408.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV, 4th ed, American Psychiatric Association, Washington, DC 1994.
- Goldstein RB, Chou SP, Smith SM, et al. Nosologic Comparisons of DSM-IV and DSM-5 Alcohol and Drug Use Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions-III. J Stud Alcohol Drugs 2015; 76:378.
- Mewton L, Slade T, Teesson M. An evaluation of the proposed DSM-5 cannabis use disorder criteria using Australian national survey data. J Stud Alcohol Drugs 2013; 74:614.