Marijuana (Cannabis) Addiction:
Cannabis Use Disorder
Despite the prevalence of use of marijuana (cannabis), many people do not realize that cannabis is an addictive drug. While estimates span a range, it is commonly reported that 9% of cannabis users develop an addictive relationship with the drug. While the psychosocial impact and consequences of cannabis addiction, better described as Cannabis Use Disorder (CUD), are not as detrimental and destructive as heroin addiction and alcoholism, CUD does negatively affect quality of life.
It is important to understand who is at risk for developing CUD and how to reduce those risks.
Addiction to Marijuana: Cannabis Use Disorder (CUD)
It is commonly reported that about 9% of individuals who initiate cannabis use will develop cannabis use disorder (CUD) in their lifetime. It is estimated that approximately 20-30% of current cannabis users have symptoms of CUD and 50% of those who use cannabis illicitly every day may meet criteria for CUD. By comparison, 15-22% of individuals who initiate alcohol use will develop alcohol use disorder in their lifetime and 8-12% of patients prescribed opioids will develop an opioid use disorder in their lifetime. It has been estimated that, globally in 2017, more than 19 million people were cannabis dependent
The risk of developing cannabis dependency is influenced by multiple factors. However, daily or near daily use is likely to increase the risk of cannabis dependence and use of more potent forms of cannabis (e.g. the flowering heads of the female cannabis plant) are also likely to increase the risk. Initiating cannabis use at an earlier age and increasing frequency of use are significantly associated with developing CUD. According to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), increasing frequency of cannabis use is also associated with a syndrome of problematic cannabis misuse—where cannabis negatively impacts a person’s life—but does not meet the criteria of CUD. Cannabis use is also associated with an increased risk of developing dependencies on substances other than cannabis.
While many people who use cannabis regularly will develop symptoms of withdrawal when abruptly discontinuing or reducing their cannabis use, it is important to understand that the severity of withdrawal symptoms does not define or predict the diagnosis of CUD. Any addiction, cannabis included, has definitive characteristics that set it apart from the use, misuse or abuse of a medication or drug. All too often, people believe that difficulty discontinuing the use of a drug or medication due to withdrawal symptoms is equivalent to an addiction to the drug or medication. It is not. To learn more about addiction and what it is,
See: Addiction Recovery.
For more information regarding cannabis withdrawal and discontinuing cannabis:
Diagnosis of CUD
Cannabis Use Disorder is a diagnosis defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition or DSM-5. The DSM is used by clinicians and psychiatrists to diagnose psychiatric illnesses. In 2013, a new version known as the DSM-5 was released. The DSM is published by the American Psychiatric Association and covers all categories of mental health disorders for both adults and children. The DSM is utilized widely in the United States for psychiatric diagnosis, treatment recommendations and insurance coverage purposes.
Symptoms of Cannabis Use Disorder – DSM-5 Criteria
At least two of the following symptoms within a 12 month period indicate Cannabis Use Disorder:
- Taking more cannabis than was intended
- Difficulty controlling or cutting down cannabis use
- Spending a lot of time on cannabis use
- Craving cannabis
- Problems at work, school and home as a result of cannabis use
- Continuing to use cannabis despite social or relationship problems
- Giving up or reducing other activities in favor of cannabis
- Taking cannabis in high risk situations
- Continuing to use cannabis despite physical or psychological problems
- Tolerance to cannabis
- Withdrawal when discontinuing cannabis.
The severity of CUD can be further stratified:
- Mild – indicates 2-3 symptoms
- Moderate – indicates 4-5 symptoms
- Severe – indicates 6 or more symptoms
It should be understood that the severity of a person’s physical addiction is unrelated to the severity of their disorder. With a list of 11 symptoms to evaluate, one can have CUD – Severe, without having any tolerance or withdrawal, typical hallmarks of addiction. By the same token, one can meet the criteria for CUD – Mild, despite experiencing severe physical tolerance and withdrawal.
Treatment of CUD
Behavioral Therapy for CUD
Currently, cannabis use disorders are primarily treated using a variety of psychosocial interventions, including Motivational Enhancement Therapy (MET) and Cognitive Behavior Therapy (CBT) as most effective.
Pharmacotherapy for CUD
Pharmacotherapy for CUD is very limited, with only a few medications identified that offer mild benefit and no medications actually FDA-approved for treating CUD. While a number of prescription medications have been evaluated, only gabapentin (Neurontin) and baclofen have been shown to reduce cravings, mostly during the withdrawal stages, although there is some preliminary research suggesting potential for long term benefit.
In a 2020 Cochrane systematic review, it was concluded that “There is incomplete evidence for all of the pharmacotherapies investigated, and for many outcomes the quality of the evidence was low or very low. Findings indicate that SSRI antidepressants, mixed action antidepressants, bupropion, buspirone and atomoxetine are probably of little value in the treatment of cannabis dependence.
Cannabanoid Replacement Therapy
Cannabanoid replacement therapy for treating CUD is analogous to the use methadone or buprenorphine (Suboxone) in treating opioid SUD. The use of cannabinoids is being studied currently and may be an effective treatment for CUD.
Dronabinol is an orally bioavailable synthetic form of THC that acts as a cannabinoid-receptor agonist at the CB1 receptor. In the US it is only approved for use for AIDS-related anorexia and nausea as a result of chemotherapy. It has shown some benefit in doses of 10–50 mg in reducing cannabis-withdrawal symptoms, with minimal side effects. It is not currently recommended as a means of long term treatment for CUD.
Cannabidiol (CBD) is the second most abundant cannabinoid found in most marijuana strains and is known to be safe and well tolerated with few adverse effects. CBD has minimal direct action at cannabinoid receptors but it has multiple pharmacologic actions including inhibiting the breakdown and reuptake of endocannabinoids and modulation of cannabinoid receptors. CBD has been shown to reduce cannabis withdrawal symptoms during cannabis abstinence and is associated with improvements in psychological well-being and thought processing in cannabis users.
CBD’s impact on the intoxication phase of cannabis
CBD’s impact on the intoxication phase of cannabis addiction in humans is complex. While it affects the implicit wanting and explicit liking, it does not influence the subjective feeling of being stoned or the craving sensation associated with the drug. Evidence suggesting that CBD has a beneficial impact on the intoxication, withdrawal, and relapse phases of cannabis addiction is preliminary at best, although intriguing due to the lack of other pharmacological options.
CBD’s impact on the reinforcing effect of cannabis.
Preliminary data also suggests a possible beneficial effect of CBD on the reinforcing effect of cannabis. In a study that evaluated the impact of varying levels of CBD and THC (low or high CBD:THC ratios) on the acute effects of cannabis intoxication, no difference in either group was found in their rating of feeling “stoned.” However, a high CBD:THC ratio was associated with lower ratings of pleasantness , or “liking.”
CBD’s impact on relapse risk of caannabis
CBD has therapeutic potential relevant for multiple conditions that underlie relapse risk, including craving induced by drug-related environmental contexts, susceptibility to stress, heightened anxiety and, possibly, impaired impulse control.
CBD’s impact of drug-related cues
CBD has shown therapeutic benefits in human and preclinical models of addiction by reducing the impact of drug-related cues in attentional bias, cue-induced craving and cue-induced reinstatement paradigms. Collectively, multiple studies indicate that CBD may have potential for treating a range of substance use disorders including cannabis, opioids, tobacco and alcohol (See: CBD – Treatment of Addiction).
CBD case reports and controlled trials
In 2015, a case report was published reviewing the use of cannabidiol (CBD) oil to decrease the addictive use of marijuana and provide anxiolytic and sleep benefits. The dosage gradually decreasing from 24 to 18 mg CBD/day. The patient reported being less anxious with an improved, regular pattern of sleep. He also indicated that he had not used any marijuana since starting the CBD oil. With the decrease in the dosage to 18 mg, the patient was able to maintain his abstinence of marijuana.
Another case report evaluated the effects of CBD on the last phases of addiction, which showed benefits for the withdrawal phase and perhaps even for the relapse phase. In this report, a 19-year-old female with cannabis dependence who experienced withdrawal syndrome when she tried to stop cannabis use, CBD was administered for 11 days (300 mg on day 1, 600 mg on days 2–10, and 300 mg on day 11). Daily assessments showed a rapid decrease in withdrawal symptoms, with resolution of symptoms by day 6. A 6-month follow-up showed a relapse in cannabis use, but at a lower frequency (one or twice a week vs. 7 days a week).
The first randomized, double blind, placebo controlled trial evaluating CBD (isolate, without terpenes) for treatment of CUD was published in 2020. Participants were initially randomised to four-week treatment with oral 200 mg, 400 mg and 800 mg CBD doses daily or placebo. The 200 mg CBD dose was discontinued early in the trial as being ineffective. At final analysis, both 400 mg and 800 mg daily doses of CBD were determined to be effective and well tolerated with no severe adverse events and 94% of participants completed treatment. Not only did participants demonstrate significantly reduced relapse rates for cannabis use but withdrawal and anxiety symptoms were also reduced and sleep was improved.
1. When taking CBD to treat CUD, additional treatment options should be considered. First, if there is an underlying chronic pain condition, anxiety or sleep concerns the choice of CBD product should include a broad spectrum profile of terpenes pertinent to the secondary conditions requiring treatment. Furthermore, the inclusion of the CB2 agonist terpene, β-caryophyllene, with the CBD should be considered.
Research suggests that CB2 receptors play a major role in alcohol reward and the CB2 receptor system may be involved in alcohol and cocaine dependence via modulation of dopamine reward pathways. In mice, β-caryophyllene has been shown to reduce voluntary alcohol intake as well as decrease cocaine self-administration. It may therefore represent a potential pharmacological target for the treatment of alcohol and cocaine abuse and by extension may offer benefit for THC abuse.
2. While existing research appears to be limited to oral treatment with CBD only, consideration should be given to sublingual administration of the CBD or inhalation, preferably vaping. The advantage of these methods allows for greater bioavailability and more rapid onset of effect that may be more effective in quelching cravings. Additionally, with inhalation, engaging the familiar ritual of smoking or vaping that is associated with the cannabis use would also be expected to reduce cravings.
Cannabis Use Disorder – Overviews
- The effects of Δ9-tetrahydrocannabinol on the dopamine system – 2017
- Psychoactive Drugs Like Cannabis -Induce Hypodopaminergic Anhedonia and Neuropsychological Dysfunction in Humans – 2021
- The acute effects of cannabidiol on the neural correlates of reward anticipation and feedback in healthy volunteers – 2020
- ‐Tetrahydrocannabinol Toxicity and Validation of Cannabidiol on Brain Dopamine Levels – An Assessment on Cannabis Duplicity – 2020
- Prenatal THC exposure produces a hyperdopaminergic phenotype rescued by pregnenolone – 2019
- Altered corticolimbic control of the nucleus accumbens by chronic Δ9-THC – 2020
- Cannabis-Induced Hypodopaminergic Anhedonia and Cognitive Decline in Humans – Embracing Putative Induction of Dopamine Homeostasis – 2021
Cannabis Use Disorder – Measuring Severity
- Is the Urine Cannabinoid Level Measured via a Commercial Point-of-Care Semiquantitative Immunoassay a Cannabis Withdrawal Syndrome Severity Predictor? – 2020
Cannabis Use Disorder – Treatment
- Cannabidiol Oil for Decreasing Addictive Use of Marijuana – A Case Report. 2015 – PubMed – NCBI
- Unique treatment potential of cannabidiol for the prevention of relapse to drug use – preclinical proof of principle – 2018
- An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use – 2019
- Pharmacotherapies for cannabis dependence – 2019
- Cannabidiol for the treatment of cannabis use disorder -Phase IIa double-blind placebo-controlled randomised adaptive Bayesian dose-finding trial – 2020
Cannabis Withdrawal Treatment – Overviews
Cannabis Withdrawal Treatment – Baclofen
Cannabis Withdrawal – Gabapentin (Neurontin)
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