What are the symptoms and diagnostic criteria of cannabis use disorder?

Cannabis Use Disorder: Symptoms and Diagnostic Criteria

Cannabis use disorder (CUD) is diagnosed when a patient meets 2 or more of 11 DSM-5 criteria within a 12-month period, representing a problematic pattern of cannabis use leading to clinically significant impairment or distress. 1

Core Diagnostic Criteria

The DSM-5 defines cannabis use disorder through 11 specific symptoms, requiring at least 2 for diagnosis: 1

Impaired Control (4 criteria)

• Using cannabis in larger amounts or over a longer period than intended 1
• Persistent desire or unsuccessful efforts to cut down or control use 1
• Spending a great deal of time obtaining, using, or recovering from cannabis 1
• Craving or strong desire to use cannabis 1

Social Impairment (3 criteria)

• Recurrent cannabis use resulting in failure to fulfill major role obligations at work, school, or home 1
• Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by cannabis 1
• Important social, occupational, or recreational activities given up or reduced because of cannabis use 1

Risky Use (2 criteria)

• Recurrent cannabis use in situations where it is physically hazardous (such as driving) 1
• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by cannabis 1

Pharmacological Criteria (2 criteria)

• Tolerance, defined by either needing markedly increased amounts to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount 1
• Withdrawal, manifested by the characteristic cannabis withdrawal syndrome or cannabis is taken to relieve or avoid withdrawal symptoms 1

Cannabis Withdrawal Syndrome

Cannabis withdrawal is now formally recognized in DSM-5 and occurs in 33% of regular users in the general population and 50-95% of heavy users in treatment settings. 1

Withdrawal Timeline

• Symptom onset: 24-72 hours after cessation 2, 3
• Peak severity: Days 2-6 2, 3
• Duration: Acute phase lasts 1-2 weeks, though cannabis craving may persist for months or years 2, 3

Withdrawal Symptoms

The characteristic withdrawal syndrome includes: 1, 2

Psychological symptoms:

• Irritability, anger, or aggression 1, 2
• Anxiety or nervousness 1, 2
• Depressed mood or dysphoria 1, 2
• Restlessness 1, 2
• Sleep disturbances (insomnia, vivid dreams) 1, 2
• Difficulty concentrating 1, 2

Physical symptoms:

• Headaches 1, 2
• Decreased appetite or weight loss 1, 2
• Abdominal pain 1, 2
• Tremors or shakiness 1, 2
• Sweating, chills, or fever 1, 2
• Nausea or vomiting 1, 2

Severity Grading

Severity is determined by the number of criteria met: 1

• Mild: 2-3 symptoms
• Moderate: 4-5 symptoms
• Severe: 6 or more symptoms

Prevalence and Risk Factors

Approximately 10% of adults with chronic cannabis use develop cannabis use disorder, with higher rates among those who initiate use at a young age. 1, 3, 4

High-Risk Populations

• Adolescents and young adults: Early onset of weekly or daily use strongly predicts future dependence 1, 3
• Heavy users: Those consuming >1.5 g/day of inhaled cannabis, >20 mg/day of THC oil, or using >2-3 times daily 2
• Individuals with psychiatric comorbidities: Higher risk for anxiety, depression, and psychotic disorders 1, 3

Clinical Significance and Complications

The clinical importance of recognizing CUD lies in its association with: 1, 2

• Difficulty quitting: Withdrawal severity correlates with worse treatment outcomes 1
• Functional impairment: School, work, and social dysfunction 1, 5
• Psychiatric complications: Major depression, suicidal ideation, and psychotic disorders 1, 3
• Cognitive deficits: Impaired memory, attention, and executive function, particularly with adolescent-onset use 3
• Cardiovascular risks: Tachycardia, myocardial ischemia, and stroke 3
• Cannabinoid hyperemesis syndrome: Cyclical vomiting relieved by hot showers in chronic users 3, 6

Distinguishing Problematic Use from Lower-Risk Use

Problematic cannabis use is characterized by: 5

• Daily or near-daily use 5
• Difficulty reducing use despite attempts 5
• Impaired school, work, or social functioning 5
• Evidence of tolerance or withdrawal 5

In contrast, lower-risk users consume cannabis occasionally without evidence of dysfunction, though no level of use is without risk, particularly for adolescents, pregnant individuals, and those with psychiatric vulnerabilities. 1, 5

Important Clinical Pitfalls

Do not dismiss patient denial of cannabis-related problems—many users attribute symptoms to other causes (stress, food, alcohol) rather than cannabis, which impedes appropriate intervention. 6

Screen all patients at least once for cannabis use, with annual screening for high-risk groups (adolescents, those with psychiatric or substance use disorders, and patients with unexplained mood, psychotic, or respiratory symptoms). 5

Recognize that modern cannabis products contain dramatically higher THC concentrations (average 17%, concentrates up to 70%), substantially elevating the risk of CUD and associated complications compared to historical products. 1, 3