What is the most accurate diagnosis for a patient with daily cannabis use, exhibiting tolerance, withdrawal symptoms, and negative consequences on relationships and work?

Substance Use Disorder with Physiological Dependence

This patient meets criteria for Cannabis Use Disorder with physiological dependence (tolerance and withdrawal). 1

Diagnostic Reasoning

This patient clearly meets DSM-5 criteria for Cannabis Use Disorder at the severe level (6 or more criteria met within a 12-month period): 2, 1

Criteria Met (At Least 6 Identified):

• Tolerance: Requires larger quantities to achieve the same calming effect 2
• Withdrawal: Experiences insomnia, irritability, stomach pain, fever, and chills on days with limited access 2, 1
• Larger amounts/longer period: Increased from 1 joint daily to 5 joints daily over the past year 2
• Social/interpersonal problems: Conflict with girlfriend about cannabis use 2
• Failure to fulfill major role obligations: Grades have dropped in college coursework 2
• Continued use despite problems: Uses at work despite fear of job loss 2
• Time spent obtaining/using: Smoking 5 times daily represents significant time investment 2

Why Physiological Dependence is Present

The presence of both tolerance AND withdrawal symptoms definitively establishes physiological dependence. 2, 1

• The patient explicitly demonstrates tolerance by needing larger quantities for the same effect 2
• The patient exhibits classic cannabis withdrawal symptoms including insomnia, irritability, and physical discomfort (stomach pain, fever, chills) when access is limited 3, 1, 4
• Cannabis withdrawal typically occurs within 24-72 hours of cessation and includes irritability, anxiety, insomnia, and physical symptoms—all present in this patient 3, 1

Why Other Options Are Incorrect

Physiological Dependence Without Meeting SUD Criteria

This is incorrect because the patient clearly meets multiple DSM-5 criteria for Cannabis Use Disorder (at least 6 criteria), far exceeding the threshold of 2+ criteria required for diagnosis. 1

Risky Substance Use Without Meeting SUD Criteria

This is incorrect because "risky use" refers to hazardous patterns that don't yet meet diagnostic thresholds—this patient has progressed well beyond risky use into a severe disorder. 2

Social Impairment Without Meeting SUD Criteria

This is incorrect because social impairment is just ONE of multiple criteria this patient meets; he has a full syndrome, not isolated social problems. 2

SUD Without Physiological Dependence

This is incorrect because the patient explicitly demonstrates BOTH tolerance and withdrawal, which constitute physiological dependence by definition. 2, 1

Clinical Implications

This patient requires intensive treatment with referral to specialized addiction services. 2

• Brief counseling alone is insufficient for substance dependence/severe SUD 2
• Consider pharmacotherapy including cannabinoid agonist replacement (nabilone or nabiximols) given the heavy use pattern (5 joints daily likely exceeds 1.5g/day threshold) 3
• Psychosocial interventions combining motivational enhancement therapy (MET) and cognitive-behavioral therapy (CBT) over more than 4 sessions show the best evidence for cannabis use disorder 5, 6
• Monitor for cannabis withdrawal syndrome during cessation attempts, which affects 50-95% of heavy users 3, 1

Critical Pitfall to Avoid

Do not dismiss cannabis withdrawal as clinically insignificant. The delayed onset (24-72 hours) and prolonged half-life of THC mean withdrawal symptoms may not be immediately recognized as related to cannabis cessation, but they are real, clinically significant, and contribute to relapse. 3, 4