Cannabis Use Disorder

Key Takeaways

• Cannabis use disorder (CUD) is a pattern of cannabis use that leads to significant distress or impairment in a person's life. It can range from mild to moderate or severe, with more serious CUD previously known as "dependence" or "addiction."

• Symptoms of cannabis use disorder include repeatedly using more than intended, ongoing unsuccessful attempts to cut back, and being unable to function in day-to-day life. Other common signs include cravings, developing tolerance, and withdrawal.

• While there are no FDA-approved medications specifically for CUD, certain pharmaceuticals may be prescribed. Treatment primarily focuses on therapy, and in severe cases, recovery from the disorder may also involve rehabilitation centers.

Understanding Cannabis Use Disorder

In recent years, cannabis has been partially or even fully legalized in many parts of the world and is now widely viewed as a socially acceptable substance. However, legalizing drugs (even those with health benefits when used according to the prescribed dosage) can lead to misconceptions surrounding the safety of the substance and an increase in usage. ^[1]

It is a pervasive myth that cannabis contains health benefits for numerous conditions and is non-addictive, when in reality, the US Food and Drug Administration (FDA) lists cannabis as a Schedule I drug, meaning it is considered to have no accepted medical use and a high potential for abuse. ^[1]

That said, the agency has approved a few cannabis-derived and cannabis-related medicines to treat a limited number of specific health conditions. According to a 2024 study, these drugs, which contain synthetic delta-9-tetrahydrocannabinol (THC) or purified cannabidiol (CBD), are only approved for treating certain seizure disorders and anorexia associated with AIDS. ^[1]

When it comes to cannabis use disorder (CUD), the condition can range from mild to severe, with moderate and severe forms of CUD previously referred to as “addiction” or “dependence.” Like other substance use disorders, cannabis can cause severe dysfunction in a person’s life, and comes with the danger of psychotic complications and even death. ^[2]

What is Cannabis?

Cannabis contains several natural chemicals that can affect the body and mind in a similar way to other drugs. The two most well-known of these chemicals are THC, which causes the "high," and CBD, which does not cause intoxication and is commonly misconstrued to contain health benefits for a wide range of mental and physical health conditions. ^[1]

Using cannabis that contains THC can lead to withdrawal symptoms upon attempting to cut down or cease use entirely, as well as mental, physical, or social problems. Along with psychosis (losing touch with reality), it has been linked to issues such as trouble sleeping and patterns of use that may lead to a substance use disorder or addiction. ^[1]

Cannabis (also known as marijuana, weed, pot, or grass) is most often consumed by smoking. When inhaled, it is quickly absorbed through the lungs and spreads throughout the body via the bloodstream. This fast delivery to the brain enhances its intoxicating effects and increases the risk of misuse and dependence. ^[1]

In contrast, when ingested orally in the form of oil, capsules, or edibles, THC enters the system more slowly, resulting in a delayed rise in blood levels. Either way, cannabis intoxication may cause a range of effects, including: ^[1]

• Euphoria

• Heightened appetite

• Dry mouth

• Red or bloodshot eyes

• Rapid heartbeat

• Restlessness

• Forgetfulness

• Difficulty concentrating

• Uncontrollable laughter

• Anxiety

• Paranoia

Less common adverse effects may include: ^[1]

• Hallucinations (Experiencing sights, sounds, or sensations that are not real)

• Delusions (Holding strong false beliefs that are not based in reality)

• Distorted sense of reality (Feeling as though the surrounding environment is unreal, distant, or dreamlike)

How Common is Cannabis Addiction

As anticipated, cannabis use has risen in recent years following changes in state laws, and, despite efforts to curb its use, is one of the most widely used drugs in the world - only following caffeine, alcohol, and tobacco. In 2021, an estimated 219 million people between the ages of 15 and 64 used cannabis, accounting for just over 4% of the global population in that age group. ^{[1] [3]}

In the same year, a large national survey in the United States reported that nearly 19% of people aged 12 and older had used cannabis within the past year. In terms of addiction to cannabis, almost 6% of individuals worldwide (16.3 million people) met the criteria for cannabis use disorder. ^[3]

While CUD occurs across all age groups, it is most common among young adults (14% among individuals aged 18 to 25), particularly people assigned male at birth, although early evidence suggests females may transition to CUD more rapidly after beginning use. The prevalence of cannabis use disorder is just under 5% in adolescents and adults aged 26 and older. ^[3]

When Does Cannabis Become a Problem?

Cannabis use disorder can be a progressive condition, meaning that it has the potential to worsen over time. The criteria for diagnosing cannabis use disorder have evolved as research has revealed more about the condition. ^[3]

In 2013, the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) combined the previously separate categories of abuse and dependence from the DSM-IV into a single disorder with 11 criteria. ^[3]

This revision added craving and withdrawal symptoms as criteria for CUD, and removed legal problems related to substance use. The 2022 update highlights impaired control, social problems, risky use, and physical symptoms such as tolerance and withdrawal. ^[3]

CUD is now classified by severity, as mild (1 to 3 criteria), moderate (4 to 5 criteria), or severe (6 or more criteria). In light of this, using cannabis is considered a clinically diagnosable problem even if a person presents with only two criteria among the list of 11. ^{[1] [3]}

Cannabis Use Disorder Symptoms

The DSM-5 defines cannabis use disorder as a pattern of cannabis use leading to clinically significant distress or impairment in areas such as social interactions, work, and daily functionality, over 12 months, indicated by at least two of the following criteria: ^[1]

• Using cannabis in larger amounts or over a longer period than originally intended

• Unsuccessful efforts to cut down or control use

• Spending a significant amount of time obtaining, using, or recovering from cannabis

• Experiencing strong cravings or urges to use cannabis

• Repeated use resulting in failure to fulfill major obligations at work, school, or home

• Continuing use despite persistent social or relationship problems

• Ceasing or reducing important social, work, or recreational activities due to prioritizing cannabis use

• Using cannabis in situations where it is physically hazardous

• Continuing use despite knowing it is causing or worsening physical or mental health problems

• Developing tolerance (needing more cannabis to achieve the same effect)

• Experiencing withdrawal symptoms when cannabis use is reduced or stopped

Additional signs and behaviors associated with CUD may include:

• Trouble with memory and learning

• Confusion or disorganized thinking

• Mood swings or sudden shifts in behavior

• Withdrawing from social connections or isolating from loved ones

• Becoming defensive, hostile, or expressing denial when confronted about cannabis use

• Loss of interest in personal hygiene or appearance

• Acting secretively to conceal cannabis use

• Reduced motivation or concern for daily responsibilities

• Hallucinations (seeing, hearing, or feeling things that are not real) and delusions (false beliefs)

Withdrawal Symptoms

• Isolation or social withdrawal

• Irritability, anger, or aggression

• Restlessness or inability to relax

• Anxiety or nervousness

• Depressed or low mood

• Difficulty sleeping (insomnia)

• Vivid or disturbing dreams and nightmares

• Reduced appetite, sometimes leading to weight loss

• Apathy and a lack of motivation

• Loss of interest in activities previously enjoyed

Less common physical symptoms may include:

• Headaches

• Tremors or shakiness

• Nausea and vomiting

• Excessive sweating

• Abdominal discomfort or pain

Causes of Addiction

With cannabis culture currently trending on social media platforms around the world, along with widespread misinformation surrounding the medicinal properties of the drug, it can be easy to use this as a justification for using more and more of it. However, cannabis is a drug, and using the substance repeatedly can lead to addiction along with other health complications.

From a scientific perspective, using substances such as cannabis for a prolonged period of time rewires the brain to seek reward in order to feel normal, consequently triggering the cycle of addiction. Furthermore, the causes of cannabis addiction can vary depending on demographic factors. ^[1]

In terms of why people start to use cannabis in the first place, studies show that among college students and young adults, the most common motivations include social conformity, curiosity or experimentation, and personal enjoyment. Around 12% report using cannabis primarily to cope with stress or to relax. ^[1]

This finding aligns with research linking cannabis use to conditions such as depression, anxiety, social anxiety, and post-traumatic stress disorder. Among pregnant individuals who use cannabis, reported reasons include managing depression, anxiety, and stress, relieving pain, addressing nausea or vomiting, and recreational use. ^[1]

From a biological perspective, reduced impulse control may increase the risk of developing substance use disorders, though it remains unclear whether this applies to cannabis. Ultimately, frequency of use is a key risk factor for cannabis addiction, but even at relatively low levels of use, certain populations (especially adolescents) are more vulnerable to developing CUD. ^[1]

Risks and Complications

Abusing cannabis comes with a host of risks and complications, ranging from lung damage to full-blown psychotic episodes, and even death. It is important to note that due to its fat-soluble nature, THC accumulates in body fat and is slowly released, remaining detectable for up to a month in chronic users, which may prolong psychoactive effects and complicate drug testing. ^{[1] [4]}

• Altered brain function: Prolonged cannabis use can alter brain function, particularly in areas related to self-awareness, motivation, and memory

• Addiction potential: While the intoxicating properties of THC reinforce the desire to use cannabis, it may not interact with dopamine in the same way as other substances

• Cognitive and emotional impairments: THC can affect learning, goal-setting, and emotional processing

• Co-occurring psychiatric conditions: Cannabis use often overlaps with anxiety and mood disorders (such as depression or bipolar)

• Short-term side effects: Even short-term cannabis use can result in impaired memory and judgment, poor coordination, and an increased likelihood of risky sexual behavior

• Pediatric risks from edibles: Children under the age of 12 are especially vulnerable to unintentional cannabis ingestion, often via edibles. This can lead to emergency visits for symptoms like drowsiness, lethargy, and (in rare cases) breathing difficulties

• Risks to infants during pregnancy: Linked to increased risks of preterm birth, low birth weight, small size for pregnancy stage, and higher odds of early post-birth death

Cannabis use can also lead to the following complications: ^[1]

• Cannabis intoxication delirium: Attention and awareness issues, as well as cognitive impairments such as memory loss or disorientation

• Cannabis-induced psychotic disorder: Hallucinations or delusions that occur during or soon after cannabis use or withdrawal

• Cannabis-induced anxiety disorder: Anxiety or panic attacks are the primary symptoms of this condition and arise during or soon after use

• Cannabis-induced sleep disorder: This disorder involves serious sleep disturbances that start during or after cannabis use or withdrawal

• Risk of suicidality and violence: Mood dysregulation due to cannabis use can increase the risk of suicidal or violent behavior

Suicide Hotlines

Suicide hotlines are confidential, around-the-clock phone services that connect people in emotional distress with trained professionals who provide immediate support and guidance. These services offer crisis intervention, mental health resources, and referrals to local care providers.

• U.S. Hotline: Dial 988 for free and receive 24/7 help

Prevention

Cannabis use disorder is a progressive condition that can range from mild to severe. In moderate to severe cases, repeated cannabis use alters the brain circuits tied to reward, motivation, and self-regulation. This contributes to cravings that reinforce the ongoing use of cannabis despite negative consequences and raises the likelihood of relapse.

In light of this, the most effective way to prevent CUD is by avoiding frequent or habitual cannabis use. This is due to the fact that with continued use over time, cannabis can reshape the brain’s natural reward and coping systems, causing the drug to feel essential for emotional balance or normal functioning.

If an individual finds it difficult to use cannabis occasionally or in controlled amounts, complete avoidance may be the safest course of action (especially since frequent use can quickly escalate into dependence). For individuals vulnerable to addiction, efforts to “cut back” rather than quit may not only be ineffective, but potentially life-threatening. ^[1]

A key step in preventing the progression to cannabis addiction is recognizing unhealthy use patterns early. Starting to use cannabis at a younger age is linked to a quicker progression to cannabis use disorder and possibly a more severe form of the disorder. For those with mild or emerging signs of CUD, choosing abstinence can significantly reduce the risk of long-term dependence. ^[3]

Criteria for Diagnosing Cannabis Addiction

A person's mental status is an important aspect of diagnosing cannabis use disorder and can provide insight into the severity of the condition. Cognitive function may be tested using tools such as three-word recall, solving multi-step math problems, or remembering details from a short fictional story. ^[1]

In individuals who have used cannabis for a prolonged period of time or in those experiencing withdrawal, symptoms of low mood should be carefully assessed to distinguish them from persistent depressive disorder or major depressive disorder. In the United States, cannabis use disorder is classified according to the criteria listed in the DSM-5 (see the symptoms section). ^[1]

Cannabis use disorder presents as both acute and chronic phases. The acute phase involves intoxication and withdrawal, often accompanied by complications like delirium (severe confusion), anxiety, psychosis, and sleep disturbances. In contrast, chronic use is marked by ongoing patterns of disordered behavior. ^[1]

The diagnostic criteria for CUD include the following specifiers: ^[1]

• Early remission: Diagnosed when a person has previously met the full criteria for CUD but has not experienced any symptoms (except craving) for at least 3 months and less than 12 months

• Sustained remission: This specifier is used when none of the criteria (aside from craving) have been met for 12 months or longer

Challenges in Diagnosing Cannabis Use Disorder

The most significant obstacle in addressing cannabis use disorder is the widespread lack of awareness surrounding the substance’s addictive qualities and frequent underdiagnosis. With growing legalization for both medical and recreational purposes, cannabis is often seen as relatively harmless (even by many healthcare providers), downplaying the risks of dependency. ^[5]

As a result, problematic use is frequently overlooked, and many people who meet the clinical criteria for CUD go without diagnosis or treatment, creating a major gap in care and intervention. It is typically only when an individual exhibits serious complications, such as psychosis or injury, that cannabis use is questioned and addressed. ^[5]

Cannabis Use Disorder Treatment Approaches

As cannabis use continues to rise globally, researchers are increasingly focused on developing effective treatments for CUD. Advancements in neuroscience and addiction medicine are deepening the modern understanding of biological factors that underlie cannabis dependence, creating new opportunities for more effective treatment approaches. ^[5]

That being said, cannabis use disorder treatment remains in its early stages, with few available medications. The pre-2024 therapy focus included behavioral interventions such as cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET), with the introduction of virtual CBT and digital monitoring tools having a positive impact on recovery maintenance. ^[5]

The newer incorporation of mindfulness-based relapse prevention (MBRP), stress management training, and trauma-informed therapy has been found to strengthen CUD recovery programs. According to the latest research, these approaches support a more sustainable and effective psychological health treatment. ^[5]

In severe cases, treatment may also be administered through rehabilitation centers, outpatient mental health services, and clinics. As recognition of cannabis dependence as a legitimate medical condition grows, healthcare providers are becoming more aware of the condition, and insurance coverage for treatment is becoming more widely available. ^[5]

Medication

There are currently no FDA-approved medications for treating cannabis use disorder. Some drugs, like gabapentin (an anti-convulsant) and N-acetylcysteine (used to treat anxiety), are being investigated but have not yet shown clear results. THC itself may help during treatment, but more research is needed to figure out how to use it safely and effectively. ^{[1] [5]}

CBD also shows promise as it may help balance certain brain systems, but again, more studies are needed to confirm how it may be of benefit. Certain medications can be used to treat specific symptoms, such as beta-blockers for a racing heart, benzodiazepines for panic attacks, antihistamines for anxiety, and antipsychotics if a person is experiencing psychosis. ^[1]

Therapy

As there is presently no standardized treatment protocol or FDA-approved medication for CUD, most treatment strategies rely on behavioral therapies. In treating cannabis use disorder, psychological interventions are believed to play a key role in addressing patterns of habitual use, identifying emotional triggers, and developing strategies to prevent relapse. ^[5]

Cognitive-Behavioral Therapy (CBT)

CBT is a central component and the most widely utilized treatment for cannabis use disorder. Cognitive behavioral therapy may help individuals with CUD to identify and challenge the thought patterns and behaviors that contribute to their cannabis use. This form of therapy also teaches coping skills to manage cravings and handle triggers, reducing the risk of relapse. ^[5]

Motivational Enhancement Therapy (MET)

Motivational enhancement therapy helps individuals with cannabis use disorder build the motivation to change their cannabis use. MET focuses on enhancing intrinsic motivation through personalized feedback and goal-setting. The therapy encourages commitment to treatment and supports sustained behavioral change. ^[5]

Mindfulness-Based Relapse Prevention (MBRP)

MBRP focuses on helping individuals with CUD develop an awareness of triggers and cravings without reacting impulsively. By practicing mindfulness techniques (such as meditation and deep breathing), patients learn to observe their thoughts and emotions non-judgmentally, build healthy coping strategies, and reduce the risk of relapse. ^[5]

Stress Management Training

Stress management training is a therapy that helps individuals with cannabis use disorder identify and manage their stress levels through various techniques. This form of therapy is similar to MBRP and teaches practical skills like relaxation exercises, deep breathing, and problem-solving to cope with stress without using cannabis. ^[5]

Trauma-Informed Therapy

Trauma-informed therapy is a treatment approach that recognizes the impact of past trauma on a person’s behavior and mental health. In cannabis use disorder, it helps individuals understand and address how trauma may contribute to their cannabis use. This therapy creates a safe and supportive environment to promote healing and reduce substance dependence. ^[5]

12-Step Rehabilitation Centres

Research has revealed that peer support groups are beneficial as part of the treatment of cannabis use disorder. In light of the fact that cannabis is recognized as a drug by Narcotics Anonymous (NA), 12-step treatment centers are a valuable resource for individuals seeking recovery from cannabis use disorder. ^[5]

Not only do these centers offer medication for cannabis-related complications and co-occurring psychiatric disorders, but they also provide a structured program based on the NA program. By choosing a 12-step treatment center, individuals can benefit from a smooth transition to NA meetings outside of the facility for ongoing support and recovery maintenance.

Long-Term Recovery from Cannabis Addiction

Long-term recovery from cannabis use disorder requires ongoing involvement in supportive practices such as those offered by Narcotics Anonymous. Consistent meeting attendance, sponsor support, fellowship activities, and regular self-reflection help individuals maintain abstinence and manage challenges that arise in recovery.

Consistent Meeting Attendance

Consistently attending meetings helps break through denial related to cannabis use and offers continual support from other recovering addicts. NA offers a supportive community where individuals with CUD can share experiences, benefit from encouragement, and be part of a supportive community.

Mentorship and Recovery Support

A sponsor is a trustworthy mentor who has completed the 12 steps and offers recovery-related guidance during moments of temptation. Sponsors help individuals with CUD address unhelpful thinking patterns by guiding them through the 12 steps. Frequent contact with a sponsor provides the accountability and encouragement essential for long-term success.

Fellowship Activities

Fellowship activities allow members to connect with others in recovery in a fun, relaxed atmosphere. These gatherings help reduce the guilt and stigma often associated with cannabis use disorder. Participating in enjoyable, substance-free activities inspires and reinforces the belief that a meaningful, cannabis-free life is not only possible, but enjoyable.

Nightly Inventory

Writing a nightly inventory allows recovering cannabis addicts to reflect on the day’s thoughts, feelings, and actions to evaluate progress in recovery. The inventory is sent to the sponsor to help identify potential triggers or issues that need attention. Regular self-reflection and feedback serve to build self-awareness and personal growth essential for maintaining abstinence.

Final Thoughts

The fairly recent legalization and societal acceptance of cannabis have unfortunately fostered widespread misconceptions about its safety and addictive potential. Despite often being perceived as harmless or even medically beneficial, cannabis is classified by the FDA as a Schedule I drug, indicating a high potential for abuse and no accepted medical use.

The widespread misinformation surrounding cannabis has contributed to an increased risk and rise of cannabis use disorder (CUD), a condition that can significantly impair an individual's life and carry the danger of severe complications, including psychotic episodes. However, with the right treatment and ongoing support, individuals with CUD can recover and even thrive.

While there are no FDA-approved medications specifically for CUD, therapies such as cognitive-behavioral therapy and motivational enhancement therapy play a major role in addressing habitual use. Other emerging therapies for CUD include mindfulness-based relapse prevention, stress management training, and trauma-informed therapy.

Long-term recovery from moderate or severe cannabis use disorder can benefit from the Narcotics Anonymous (NA) program. As awareness of cannabis dependence as a legitimate medical condition grows, more and more individuals are seeking treatment, attaining recovery, and living fulfilling substance-free lives.