Cannabis Abuse and Dependence (305.20/304.3)

DSM-IV-TR criteria

A. Cannabis is a generic term used to denote the several psychoactive preparations of the plant Cannabis sativa. The major psychoactive constituent in cannabis is ∆-9 tetrahydrocannabinol (THC). Cannabis impairs cognitive development (capabilities of learning), including associative processes; free recall of previously learned items is often impaired when cannabis is used both during learning and recall periods

B. Cannabis impairs psycho-motor performance in a wide variety of tasks, such as motor coordination, divided attention, and operative tasks of many types; human performance on complex machinery can be impaired for as long as 24 hours after smoking as little as 20 mg of THC in cannabis; there is an increased risk of motor vehicle accidents among persons who drive when intoxicated by cannabis.

C. Some difficulties when cannabis is used may interfere with academic or occupational achievement or with social communication. Coding should be in AXIS I: CLINICAL DISORDERS/OTHER DISORDERS THAT MAY BE A FOCUS OF CLINICAL ATTENTION Under Substance-related disorders.

Associated features

Cannabis used during pregnancy is associated with impairment in fetal development leading to a reduction in birth weight; it also may lead to postnatal risk of rare forms of cancer although more research is needed in this area. Marijuana is the most used illicit drug in the United States. According to the 1994 National Household Survey on Drug Abuse, averages of 10 million Americans use marijuana each month. Within a few minutes of inhaling marijuana smoke, users likely experience dry mouth, rapid heartbeat, some loss of coordination and poor sense of balance, and slower reaction times, along with intoxication. Blood vessels in the eye expand. For some people, marijuana raises blood pressure slightly and can double the normal heart rate. This effect can be greater when other drugs are mixed with marijuana.
Cannabis has been proven to cause damage with short term memory. This is caused by the THCs effect on the hippocampus, the area of the brain responsible for memory formation
Cannabis smoke contains 50 – 70 percent more carcinogenic hydrocarbons than tobacco smoke. This has been suspected to be more likely to cause lung cancer. People inhaling the smoke also tend to hold the smoke in their lungs longer than cigarette smoke.THC has also been proven to inhibit a persons immune system, making them much more vulnerable to infectious diseases.

Child vs. adult presentation

NIDA’s 1995 Monitoring the Future study found that from 1991 to 1995, marijuana use in the 12 months before the surveys rose from 23.9 to 34.7 percent among the Nation’s 12th graders, from 16.5 to 28.7 percent among 10th graders, and from 6.2 to 15.8 percent among 8th graders. Children often present about the same effects as adults on the substance directly after inhalation (see associated features). Peer pressure is a factor for children if other delinquents their age are engaged in use or around somebody who is. It is continuously becoming more and more popular among a variety of ages. Adult use is very likely to have risen as well or just continued their use through high school and college because of their liking of the substance and the good times associated with it.

Gender and cultural differences in presentation

The Drug Abuse Warning Network (DAWN), a system for monitoring the health impact of drugs, estimated that, in 2001, marijuana was a contributing factor in more than 110,000 emergency department (ED) visits in the United States, with about 15 percent of the patients between the ages of 12 and 17, and almost two-thirds were male. On average, 53 percent of juvenile male and 38 percent of juvenile females arrested and tested positive for marijuana; males are more likely to be associated with such deviant behavior but females are not restricted from use; there is just a difference in amount use and the frequency of occurrence. Cultures in America are more likely to run across this cannabis substance because of the diversity and the many people in the United States.

Epidemiology

Cannabis is by far the most common and widely cultivated, trafficked, and abused illicit drug. Half of all drug seizures worldwide are related to cannabis. The geographical spread of those seizures is also global, covering practically every country of the world. About 147 million people, 2.5% of the world population, consume cannabis (annual prevalence) compared with 0.2% consuming cocaine and 0.2% consuming opiates.

Etiology

Cannabis is often blamed as the “gateway” drug but no evidence seems to be able to support this claim. There is a correlation between association of “having a good time” and reuse. If the user learns to associate enjoyment with the activity then he/she will be much more likely to use it again. People can build up a tolerance to cannabis so they tend to use and abuse more the longer they use the substance. Although the causes of use vary from person to person, some use it for “medicinal uses.” Cannabis, and the THC that is in it, is often used to treat nausea, pain, and even glaucoma. Also, it has been used in cancer patients to get them to eat. This is still, however, considered illegal in most states.

Empirically supported treatments

Treatment programs directed at marijuana abuse are rare, partly because many who use marijuana do so in combination with other drugs such as cocaine and alcohol. Therapy may be individual treatment that includes motivational interviewing and advice on ways to reduce marijuana use. By increasing patients’ awareness of what triggers their marijuana use, they may be able to better manage their addiction. Four of the most commonly used treatments are: Basic principles, Psychotherapy, Behavioral Therapy, and 12-step programs. Basic Principles treatment includes: education, urine tests, and communication. Psychotherapy focuses on the reasons why the patient is using, and often encorporates other users of the substance who are currently battling with the same issues. Behavioral Therapy teaches users of the substance to focus on other ways to reduce anxiety with special emphasis is on relaxation techniques, self-control skills, and assertiveness training. Twelve-Step programs, such as Narcotics Anonymous (NA), focus on building a support group that is battling with similiar issues, relying on a higher power to remove the obsession to use the substance, and helping others in their battle with the substance.

DSM-V Proposed Changes: adding “Cannabis-Use Disorder” and “Cannabis Withdrawal”

DSM-V Cannabis-Use Disorder Criteria:

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

4. tolerance, as defined by either of the following:

a need for markedly increased amounts of the substance to achieve intoxication or desired effect
markedly diminished effect with continued use of the same amount of the substance

(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. withdrawal, as manifested by either of the following:

the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. the substance is often taken in larger amounts or over a longer period than was intended

7. there is a persistent desire or unsuccessful efforts to cut down or control substance use

8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

9. important social, occupational, or recreational activities are given up or reduced because of substance use

10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

11. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

Moderate: 2-3 criteria positive
Severe: 4 or more criteria positive

Specify if:

With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)

Course specifiers (see text for definitions):

Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment

DSM-V Cannabis Withdrawal Criteria:

A. Cessation of cannabis use that has been heavy and prolonged

B. 3 or more of the following develop within several days after Criterion A:

Irritability, anger or aggression
Nervousness or anxiety
Sleep difficulty (insomnia)
Decreased appetite or weight loss
Restlessness
Depressed mood
Physical symptoms causing significant discomfort: must report at least one of the following: stomach pain, shakiness/tremors, sweating, fever, chills, headache

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

D. The symptoms are not due to a general medical condition and are not better accounted for by another disorder

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