Condition

Cannabis Use Disorder

Editors: Kimberly Mercer PhD; Esther Jolanda van Zuuren MD; Alexander Rae-Grant MD, FRCPC, FAAN

Next Section >

Background Information

Description

  • Cannabis use disorder (CUD) is a chronic, relapsing condition that features a loss of control over cannabis use, with continued use despite adverse consequences, including physical or psychological harm.
    1
    ,
    2
  • For the diagnostic criteria for CUD and cannabis withdrawal, see Diagnostic Criteria.

Also Called

  • Cannabis dependence
  • Unhealthy cannabis use (previously cannabis misuse)

Definitions and Additional Background Information

  • "Cannabis" and "marijuana" are frequently used to refer to plants of the genus Cannabis, any of the > 500 chemicals and compounds that can be extracted from the plant, synthetic analogues of those substances, and derivative substances.
    1
    ,
    2
    • Delta-9-tetrahydrocannabinol (THC) is the main psychoactive compound of the cannabis plant and leads to most of the euphoric and other psychological and physiological effects people seek when they use cannabis recreationally.
    • Cannabidiol (CBD) is another psychoactive compound which may have some anxiolytic and analgesic effects. However, its effects are not euphoric and so CBD by itself is not thought to lead to a use disorder.
  • The most common ways cannabis is used are:
  • Cannabis intoxication occurs shortly following the use of cannabis and includes transient psychological and physical effects.
    1
    • Psychological effects may include any of the following: euphoria (“high”), relaxation, sedation, increased appetite, and impaired short-term memory, concentration, and psychomotor coordination. Less common effects may include anxiety, paranoia, and psychotic symptoms.
    • Physical effects may include impaired motor coordination, slurred speech, dry mouth, conjunctival injection, tachycardia, orthostatic hypotension, and horizontal nystagmus.
  • Hazardous cannabis use is a pattern of use in which the risk of harmful physical or mental health consequences to the person or others due to cannabis use warrants attention and advice from clinicians (World Health Organization International Classification of Diseases, 11th Revision (ICD-11) Jan 2024).
  • Cannabis withdrawal refers to symptoms that occur after abruptly stopping or significantly reducing the use of cannabis products containing THC.
    3
  • For diagnostic criteria for cannabis use disorder, cannabis dependence, and cannabis withdrawal by the Diagnostic and Statistical Manual of Mental Disorders 5th ed., Text Revision (DSM-5-TR) and the ICD-11, see Diagnostic Criteria in Diagnosis.
  • In the United States, cannabis is a Schedule 1 substance on the federal level. However, some form of it is allowed in almost all states and territories of the United States. For details including the state-specific status of cannabis, see:
  • For more details related to cannabis use in general, including effects on driving, see:

Epidemiology

Incidence/Prevalence

  • Cannabis is one of the most commonly used psychoactive substances world-wide.
    1
    • Globally, about 209 million persons aged 15-64 years (4%) are estimated to have used cannabis in 2020.
    • In the United states, about 52.4 million persons aged ≥ 12 years (18.7%) are estimated to have used cannabis in 2021.
  • Cannabis use disorder (CUD) is reported in about 10% of persons who regularly use cannabis and about 33% of persons who use cannabis daily. CUD rates are highest in young adults, with a median age of onset of 22 years.
    1
    ,
    2
  • STUDY SUMMARY
    cannabis use disorder reported in 29% of adults who used cannabis for medicinal purposes within the past 6-12 months
    SYSTEMATIC REVIEW: Drug Alcohol Depend 2024 Apr 1;257:111263Full Text

Risk Factors

  • Risk factors for cannabis use and CUD are similar to risk factors for other substance use and substance use disorders.
    2
  • In adolescents, the risk for CUD in young adulthood increases with the number of risk factors the person has.
    2
  • Risk factors related to cannabis use:
    1
    ,
    2
    • Greater frequency of cannabis use, with reported rates of CUD ranging from 3.5% for cannabis use < 12 days/year to 36% for cannabis use > 4 days/week.
    • Greater potency of the cannabis used, which has doubled over the past 20 years
    • Younger age of starting cannabis use, which is associated with more rapid development and more severe onset of CUD
  • Biopsychosocial risk factors:
    1
    ,
    2
    • Personal history of mental health conditions and certain behaviors, such as antisocial behavior, impulsiveness, and novelty seeking
    • Poor ability to manage emotions and interact with environmental influences, such as with peers or cultural norms
    • Biological make-up, including genetics that may predispose persons to cannabis and substance use disorders
    • The number and type of negative life events, including adverse childhood experiences and stressful experiences, such as job loss or divorce
    • The use of other psychoactive substances, including alcohol or tobacco
    • Antisocial behavior, novelty seeking, and impulsivity
    • Early onset behavioral difficulties and adverse affiliation with peers
    • Permissive attitudes towards substance use or cannabis use by parents
    • Substance use of peers, which is particular important for adolescents
    • Social disadvantages
    • Moving away from home
    • Dropping out of school
    • Acts of violence
  • STUDY SUMMARY
    past-year alcohol use disorder, past-year psychiatric disorder, and social deviance each appear associated with increased likelihood of CUD
    COHORT STUDY: Addiction 2014 Feb;109(2):284

  • STUDY SUMMARY
    increasing frequency of cannabis use before age 17 years may increase risk of CUD at age 30 years
    META-ANALYSIS: Lancet Psychiatry 2014 Sep;1(4):286

  • STUDY SUMMARY
    male sex, externalizing disorder before age 14 years, and childhood maltreatment appear associated with persistently increasing risk for CUD
    COHORT STUDY: Addiction 2017 Feb;112(2):279

Associated Conditions

  • CUD often co-occurs with other substance use disorders and other psychiatric conditions.
    1
    ,
    2
    • The most common co-occurring substance use disorders in persons with CUD are alcohol or tobacco use disorder. The risk of a co-occurring substance use disorder is greater with severe CUD than with mild or moderate CUD.
    • The most common co-occurring psychiatric conditions (other than substance use disorder) are depression, posttraumatic stress disorder , and generalized anxiety disorder.
      • A coexisting psychiatric disorder is more likely with more severe CUD and a poor response to CUD treatment.
      • Persons who use cannabis who also use a greater number of different types of substances may have a greater number and greater severity of other psychiatric conditions, including psychotic symptoms, depression, anxiety, and mania.
    • See also Co-occurring Substance Use Disorder and Mental Health Disorder.
  • Persons with CUD who recently stopped or reduced cannabis use may experience withdrawal.
    1
    • Psychological symptoms may include anxiety, decreased appetite, depressed mood, irritability, problems sleeping, and restlessness.
    • Physical signs may include abdominal cramps, muscle aches, tremor, headache, sweating, chills, and weight loss.
    • See also the Diagnosis section for withdrawal criteria and Education and Lifestyle Management for management suggestions.
  • Persons with CUD may also have other cannabinoid-related symptoms or disorders, including:
    1
    • Acute cannabis intoxication
    • Cannabis hyperemesis syndrome, if patient also has cyclic vomiting with cannabis use
    • Cannabis-induced delirium, which is typically hyperactive delirium
    • Cannabis-induced anxiety disorder, manifesting as general anxiety or panic attacks
    • Cannabis-induced psychosis
    • Cannabis-induced sleep disorder, typically manifesting as insomnia
    • See also Adverse Effects of Cannabinoids.
  • Cannabis may have interactions with other substances and medications. For example, CNS depressants may increase the sedative effects of cannabis. See the Drug Interactions section in Adverse Effects of Cannabinoids for more information.
  • STUDY SUMMARY
    cannabis use appears to be associated with incident and persistent alcohol use disorder
    COHORT STUDY: Drug Alcohol Depend 2016 Apr 1;161:363

Etiology and Pathogenesis

Causes

  • Cannabis use disorder (CUD) likely develops due to a combination of genetic, neurobiological, environmental, and social factors along with mental health comorbidities.
    1
    ,
    2

Pathogenesis

  • The effects of cannabis are produced by an interaction between the main psychoactive cannabis constituent delta-9-tetrahydrocannabinol (THC) and the endocannabinoid system.
    1
    • The endocannabinoid system is comprised of two main cannabinoid receptors, cannabinoid receptor type 1 (CB1) and cannabinoid receptor type 2 (CB2).
    • CB1 receptors relevant to cannabis use disorder (CUD) are found in neurons and glia cells throughout the brain and the nervous system, particularly in brain regions that may mediate the main effects of THC, such as:
      • Hippocampus (memory)
      • Basal ganglia and cerebellum (coordination of motor function)
      • Cerebral cortex (subjective experience and executive function)
      • Ventral tegmental area (reward function)
    • CB2 receptors are found mostly in immune cells and sparsely in the nervous system.
  • THC is a partial agonist of both CB1 and CB2 receptors. Some synthetic cannabinoids are full agonists of the CB1 receptor. Cannabidiol (CBD) appears to have limited interactions with CB1 and CB2 receptors.
    1
  • THC, as well as other some cannabinoids, modulate brain function mainly through the CB1 receptor.
    1
    ,
    2
    • The time until THC reaches peak plasma concentrations depends on the route of administration.
      • THC is rapidly absorbed when inhaled, which can appear in plasma within seconds and reach peak concentrations within 5-10 minutes.
      • THC is slowly absorbed when taken orally, with peak plasma concentration occurring in 2-6 hours.
      • Persons may inadvertently overdose by expecting an immediate effect and taking repeated doses, particularly if they are taking it orally.
    • CB1 receptors indirectly increase the activity of the dopaminergic system, which mediates the rewarding effects of cannabis and other substances.
      • THC indirectly increases dopaminergic activity by influencing the firing of dopaminergic neurons in the midbrain, such as in the ventral tegmental area (VTA).
      • Within the VTA, CB1 receptors activated by THC are thought to inhibit gamma-aminobutyric acid (GABA)ergic neurons, which indirectly increases the activity of excitatory glutamatergic neurons, which in turn, increases the activity of the dopaminergic system.
  • Long-term and chronic use of cannabis results in the down regulation of CB1 receptors, particularly in persons with cannabis use disorder (CUD).
    1
    ,
    2
    • There may be an inverse association between the density of CB1 receptors in cortical regions and the duration of cannabis smoking.
    • Persons who are heavy cannabis users may have a reduced ability to synthesize dopamine, which may not be present in persons with mild or moderate CUD.
  • Discontinuation of cannabis use after long-term use is reported to normalize CB1 receptor density a few days to 4 weeks following cannabis withdrawal.
    2
  • Sustained abstinence of cannabis following chronic cannabis use may also improve learning and memory impairments associated with cannabis intoxication.
    2
  • Gene-environment interactions, particularly involving serotonin transporter promoter (5-HTTLPR) polymorphism, may be involved in development of substance use disorders in persons with history of childhood adversities (BMJ Open 2019 Sep 4;9(9):e030328).
Next Section >

Published by EBSCO Information Services. Copyright © 2025, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

DynaMed Levels of Evidence

Quickly find and determine the quality of the evidence.

DynaMed provides easy-to-interpret Level of Evidence labels so users can quickly find and determine the quality of the best available evidence. Evidence may be labeled in one of three levels:

1Level 1 (likely reliable) Evidence
Representing research results addressing clinical outcomes and meeting an extensive set of quality criteria which minimizes bias.
There are two types of conclusions which can earn a Level 1 label: levels of evidence for conclusions derived from individual studies and levels of evidence for conclusions regarding a body of evidence.
2Level 2 (mid-level) Evidence
Representing research results addressing clinical outcomes, and using some method of scientific investigation, but not meeting the quality criteria to achieve Level 1 evidence labeling.
3Level 3 (lacking direct) Evidence
Representing reports that are not based on scientific analysis of clinical outcomes. Examples include case series, case reports, expert opinion, and conclusions extrapolated indirectly from scientific studies.

Grades of Recommendation

Guideline producers are now frequently using classification approaches for their evidence and recommendations, and these classifications are recognized and requested by guideline users. When summarizing guideline recommendations for DynaMed users, the DynaMed Editors are using the guideline-specific classifications and providing guideline classification approach when this is done.

Download the full version of Levels of Evidence