Cannabis Use Disorder, Moderate to Severe
This patient qualifies for a diagnosis of Cannabis Use Disorder (CUD), likely at the moderate to severe level, based on daily cannabis use ("bowl of weed daily") meeting DSM-5 criteria. 1 The history of opioid addiction (Percocet, Vicodin, OxyContin) represents a separate diagnosis—Opioid Use Disorder in sustained remission (if currently abstinent)—but does not change the cannabis diagnosis. 2
Diagnostic Framework
Cannabis Use Disorder Diagnosis
DSM-5 requires ≥2 of 11 criteria within a 12-month period for CUD diagnosis. 1 Daily use strongly suggests multiple criteria are met, including:
- Larger amounts/longer periods than intended
- Craving or strong desire to use
- Tolerance (needing more to achieve desired effect)
- Continued use despite problems 1
Severity classification: Mild (2-3 criteria), Moderate (4-5 criteria), Severe (≥6 criteria). 1 Daily cannabis use typically indicates moderate to severe CUD, as 50-95% of heavy users meet criteria for the disorder. 2
Cannabis withdrawal is now recognized in DSM-5 (not in DSM-IV), occurring in 50-95% of heavy users and includes irritability, anxiety, sleep disturbances, decreased appetite, restlessness, and physical discomfort within 3 days of cessation. 2, 1
Opioid Use Disorder History
The prior addiction to prescription opioids (oxycodone/hydrocodone) constitutes a separate diagnosis of Opioid Use Disorder. 3, 4 If the patient is currently abstinent from opioids, specify "in sustained remission" (≥12 months without meeting criteria except craving). 5
Patients with personal history of substance abuse have increased risk for developing additional substance use disorders. 3, 6 This patient's opioid addiction history places them at higher risk for severe CUD and complicates treatment planning.
Critical Diagnostic Considerations
DSM-5 Eliminated Polysubstance Dependence
Do not diagnose "polysubstance dependence"—this category was eliminated in DSM-5. 2 Each substance requires its own specific use disorder diagnosis.
Diagnose separately: Cannabis Use Disorder (current) AND Opioid Use Disorder (specify current status—active use, early remission, or sustained remission). 2
Important Diagnostic Pitfalls
Urine drug testing alone cannot diagnose substance use disorder and should never be used in isolation for diagnosis. 2 Clinical assessment of the 11 DSM-5 criteria is required.
Do not count tolerance and withdrawal toward CUD diagnosis if cannabis is used for supervised medical purposes with no other criteria present. 1 However, daily recreational use without medical supervision does not fall under this exception.
History of substance abuse increases risk but does not automatically mean current CUD is severe—assess current symptom count systematically. 1, 6
Risk Factors Present
Prior opioid addiction significantly elevates risk for CUD and other substance use disorders. 3, 6 Patients with substance abuse history have higher rates of psychiatric comorbidity (depression, PTSD, antisocial personality disorder). 7, 6
Daily cannabis use in someone with opioid use disorder history warrants screening for: 7, 6
- Concurrent alcohol or stimulant use disorders (cocaine, methamphetamine)
- Major depression (most common comorbidity, 21% lifetime prevalence in substance users)
- Anxiety disorders and PTSD
- Suicidal ideation (often undercounted in substance users)
Clinical Documentation
Document specific DSM-5 criteria met (e.g., "Patient reports using larger amounts than intended, craving, continued use despite relationship problems, tolerance"). 1, 8
Specify severity level based on symptom count: moderate (4-5 criteria) or severe (≥6 criteria). 1
Document opioid use disorder status: "Opioid Use Disorder, [severity], in sustained remission" if abstinent ≥12 months. 5
Avoid stigmatizing language—use person-first terminology ("patient with cannabis use disorder" not "cannabis abuser"). 1
Treatment Implications
Severe CUD requires intensive treatment with referral to specialized addiction services. 9 Motivational enhancement therapy and cognitive-behavioral therapy show best evidence for CUD. 9
Monitor for cannabis withdrawal during cessation attempts—affects 50-95% of heavy users and contributes to relapse if untreated. 9
Screen for cannabinoid hyperemesis syndrome in long-term daily users (cyclical vomiting relieved by hot showers). 1
Assess for psychiatric comorbidities given dual substance use disorder history—depression, anxiety, and trauma are highly prevalent and require concurrent treatment. 7, 6