What are the diagnostic criteria for cannabis use disorder?

Diagnostic Criteria for Cannabis Use Disorder

Cannabis use disorder is diagnosed when a patient meets two or more of the eleven DSM-5 criteria, with severity classified as mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria). 1

Core Diagnostic Criteria

The DSM-5 criteria for cannabis use disorder include:

1. Taking cannabis in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful efforts to cut down or control cannabis use
3. Spending a great deal of time obtaining, using, or recovering from cannabis
4. Craving or strong desire to use cannabis
5. Recurrent cannabis use resulting in failure to fulfill major role obligations
6. Continued cannabis use despite persistent social or interpersonal problems caused by cannabis
7. Important activities given up or reduced because of cannabis use
8. Recurrent cannabis use in physically hazardous situations
9. Continued cannabis use despite knowledge of physical or psychological problems likely caused by cannabis
10. Tolerance (needing increased amounts for same effect or diminished effect with same amount)
11. Withdrawal (experiencing cannabis withdrawal syndrome or using cannabis to relieve withdrawal)

Severity Classification

• Mild: 2-3 criteria met
• Moderate: 4-5 criteria met
• Severe: 6 or more criteria met 1

Important Clinical Considerations

Medical Cannabis Exception

An important exception applies to supervised medical cannabis use. When cannabis is used appropriately under medical supervision:

• Tolerance and withdrawal alone (without other criteria) should not be considered diagnostic of cannabis use disorder
• These physiological adaptations are normal when cannabis is used appropriately for medical purposes 1

Cannabis Withdrawal Syndrome

Cannabis withdrawal syndrome is now recognized in DSM-5 and typically:

• Begins 24-72 hours after cessation of regular cannabis use
• Peaks within the first week
• Can last 1-2 weeks 2

Symptoms include:

• Psychological: Irritability/anger, anxiety, restlessness, mood changes, sleep disturbances, decreased appetite
• Physical: Headaches, abdominal pain, tremors, sweating, fever, chills 2

High-Risk Populations

Patients at highest risk for developing clinically significant cannabis use disorder include those:

• Consuming >1.5 g/day of inhaled cannabis
• Using >300 mg/day of CBD-dominant oil
• Using >20 mg/day of THC-dominant cannabis oil
• Using cannabis products with unknown CBD/THC content more than 2-3 times daily 2

Screening and Assessment

When evaluating for cannabis use disorder, assessment should include:

• Frequency and quantity of cannabis use
• THC content of products used
• Duration of use (>1 year increases dependence risk)
• Method of consumption
• Presence of preoccupation with acquisition
• Compulsive use patterns
• History of relapse or recurrent use 3

Clinical Implications

Cannabis use disorder has significant clinical implications:

• Increased risk of developing psychotic disorders with chronic and early use 4
• Worsened outcomes in patients with existing psychotic disorders (decreased medication adherence, more psychiatric hospitalizations) 4
• Cognitive impairment affecting memory, attention, and complex cognitive processes 2
• Higher risk of adverse neurodevelopmental effects in adolescents and young adults 2
• Potential for cannabinoid hyperemesis syndrome with chronic daily use 2

Screening Tools

For busy clinical settings, the 3-item Cannabis Use Disorder Identification Test-Short Form (CUDIT-SF) can be used as an initial screening tool:

• Using a cut score of 2, it identifies approximately 78% of patients meeting DSM-5 criteria for cannabis use disorder
• Shows high agreement (93-98%) with the full CUDIT-R 5

Common Pitfalls to Avoid

1. Overlooking medical cannabis use: Remember that tolerance and withdrawal alone are not diagnostic in patients using cannabis appropriately under medical supervision

2. Failing to distinguish between occasional use and problematic use: Lower-risk cannabis users smoke, inhale, or ingest cannabis occasionally without evidence of dysfunction; problematic users often use cannabis daily with impaired functioning 6

3. Misdiagnosing polysubstance use: The DSM-5 eliminated polysubstance dependence as a diagnosis 1

4. Ignoring withdrawal symptoms: Cannabis withdrawal is now recognized as clinically significant and can lead to relapse if not properly addressed 1, 2

5. Focusing only on frequency of use: Assessment should include multiple dimensions including quantity, potency, method of use, and functional impact 2, 6