Cannabis Use Disorder is a terrible condition that is rampant among cannabis users. Even you or one of your closest family members could be suffering from Cannabis Use Disorder and not even know it. Just smoking one bong or marijuana cigarette can get you addicted, and make you the next victim of this terrible disease.
Sounds familiar, right? The propaganda campaigns of the early 20th century led to the scheduling and prohibition of Cannabis sativa. The plant was scheduled under category I, meaning it is highly addictive and has no known medical value. Other Schedule I Substances include peyote, LSD, and MDMA. In comparison, Schedule IV drugs, those that have low potential for abuse or dependency, includes Xanax, Valium, Ambien, and Tramadol. but they expect us to just ignore the fact that benzodiazepines such as Xanax killed more than 10,684 Americans in 2016 alone.
To anyone who studies the science, it is obvious that drug scheduling has nothing to do with the medical or cultural evidence surrounding the substances. This means that when many people hear phrases such as ‘Cannabis Use Disorder’ it evokes different ideas to different groups of people. Cannabis users immediately discount it, and assume it is propaganda, it carries about as much weight as the terms ‘gateway drug’ or ‘marijuana needle.’ But, among the politicians and doctors it is a common phrase, and one that is immediately accepted with the same authority as a diagnose of alcoholism or dementia. So, obviously there is a functional divide that needs to be investigated.
What is Cannabis Use Disorder?
Cannabis Use Disorder is listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The manual serves as the principal authority of psychiatric diagnoses in the US and, to a large degree, abroad. Both Cannabis Use Disorder and Cannabis Withdrawal Syndrome were defined and added to this document in the 2013 version.
According to the DSM-5 criteria, Cannabis Used Disorder (CUD) is defined by the continued use of cannabis despite serious distress or impairment. Basically it is when people continue to use it, despite its harmful effects. Alongside this, cannabis-induced states were also included in the DSM-5, including; Cannabis Intoxication, Cannabis Withdrawal, Cannabis Intoxication-Delirium, Cannabis-Induced Psychotic Disorder, Cannabis Induced Anxiety Disorder, and finally, Cannabis-Induced Sleep Disorder.
How is CUD defined?
The DSM-5 lists 11 typical symptoms of CUD as a guide for clinicians to use in diagnosis, and rates the severity of the disorder based on how many of the listed criteria are met: mild = 2-3 symptoms, moderate = 4-5 symptoms, and severe = 6+ symptoms. These symptoms include:
- Using cannabis for a minimum of one year with the presence of at least two of the following symptoms accompanied by serious impairment of functioning and agitation.
- Used in larger amounts over a longer time than what was intended.
- Repeatedly tried to stop or lessen the amount of cannabis used.
- Unusual amount of time is spent trying to get, use and/or recover from cannabis effects.
- Having cravings for cannabis, such as thoughts and images, dreams, and perceiving its smell because of an obsession with it.
- Keep on using cannabis even in light of the fact that it has negative consequences, such as others warning to leave the relationship or being left by a partner or friends, poor job performance and criminal charges.
- Using cannabis is more important than other areas of life—job, school, hygiene and responsibilities to family members and friends.
- Using cannabis and taking dangerous risks, such as driving a car.
- Using cannabis even though the person is aware of the physical and psychological problems he has because of it (lack of motivation, chronic cough).
- Builds a tolerance to cannabis—taking larger amounts to get the psychoactive effect experienced when it was first used.
- Cannabis is used to halt the symptoms of withdrawal.
Other studies have estimated that about one in every 10 cannabis users will develop CUD. With cannabis being the most widely used illicit substance today, surely CUD must be a global epidemic. So, how is it being treated?
How is CUD Diagnosed and Treated?
CUD diagnosis is quite subjective. Although tests for the metabolites of THC can be given, these do not diagnose CUD. A positive test for THC does not necessarily mean that the person has CUD, and a negative one cannot rule it out. So, diagnoses rely not on empirical or quantitative metrics, but instead on self-reporting or observations of the symptoms listed above.
Cannabis Use Disorder is generally treated through three methods. The first is through Individual or group therapy following the Rational Emotive Behavior Therapy model. The second is through Psychoeducation, or the process of re-education to remove false beliefs such as the notion that cannabis ”use causes no harm.” And lastly, twelve step programs that help to replace relationships with harmful people to ones that are with “sober, responsible individuals.”
Early remission is achieved by not having any of the above listed symptoms for at least 3 months, and complete remission occurs when no symptoms have been experienced for 1 full year. There are currently no FDA approved medications approved to treat or cure CUD.
How Prevalent is CUD today?
Despite the almost ubiquitous use of cannabis in the US today, there is very little data on the prevalence of CUD. We can look to several studies to learn just how prevalent it is among certain populations. For example, a 2012 study looking at data from the Veterans Affairs Health Care System found an astonishingly high increase of 50% over the period from 2002-2009. However, when we break the data down, we find that increase is from 0.66% to 1.05%. Not very high for a cohort of patients with serious psychiatric problems due to the trauma of war.
There are no studies which have attempted to quantify the prevalence of CUD in US or Global populations. Instead, rates of cannabis abuse are used as a proxy. According to a 2006 review, “among over 60 large epidemiologic surveys conducted worldwide since the early 1980s, only eight have reported the rates of cannabis abuse and/or dependence using standardized diagnostic criteria.” So, if it is not important enough for groups like the CDC to keep records, and even the AMA that sets the definitions has not collected data, then why is CUD being brought up so often in government reports when discussing the legalization or rescheduling of cannabis?
Why are we hearing about CUD?
Despite the rhetoric, no study has ever proven THC to be addictive , and even those looking at dopamine reward circuits associated with pleasure seeking addictive behaviors have failed to provide sufficient evidence for cannabis in the same way as alcohol or opioids. As we have seen here, the criteria for Cannabis Use Disorder are not only general, they are largely subjective. There is are no diagnostic tests that a doctor can run, no data to be analyzed, and no scans or imaging to look at.
We do not know the prevalence of CUD, nor do we have data on the socio-economic consequences of it. What we do have abundant data on, however, is the efficacy of cannabis in the treatment of a wide range of clinically diagnosed diseases which do actually include biomarkers and objective metrics of disease progression and symptoms. We have data on the number of people diagnosed with disease such as cancer, MS, Parkinson’s, or epilepsy. And we also have data on how many of them use cannabis, and how many of them report benefits and significant side effects. We use polysomnography to quantify the effects of cannabis on sleep. And we use both animal and human pain response models to quantify the efficacy of THC or CBD as an analgesic.
The data collected over the last century, despite restrictions on research, has proven that cannabis has real and quantifiable medical value. The mechanism of actions for these effects is also largely understood, and has led to the development of entirely new classes of prescription drugs based on understanding the function of the endocannabinoid system. Furthermore, there has never been a single study to quantify the addictive potential of cannabis, nor explain a biological mechanism for it.
What are the incentives behind a CUD diagnosis?
Cannabis is not the most widely used illicit substance on earth because it has high costs for public health. It is so widely used because it works, and because most users enjoy it or receive benefits from its use. Taking all that into consideration, it is hard not to assume that those perpetuating and promoting disorders such as CUD may have ulterior motives. Could it be that psychiatrists have an inventive to define new disorders that they can then earn money or prestige by publishing about or treating?
This was the British Psychological Society’s criticism of the AMA’s DSM-5, who said it was “clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements.” It went on to comment on the overall effect that the DSM-5 updates would have on the industry, as well as the country as a whole, stating, “the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences… which do not reflect illnesses so much as normal individual variation.”
Additionally, could it be that governments and groups like the DEA are incentivized to promote views that paint cannabis as a dangerous and insidious substance because they are earning money on its prohibition? Just in 2018, 663,367 Americans were arrested for cannabis possession. Globally, the war on drugs costs countries about $100 Billion dollars each year, 40% of that coming from the US. This money is not only going to groups that enforce drug laws, like the DEA, but also to state and local police, courts, jails, bail bonds lenders, lawyers, and all their auxiliary support networks. To decriminalize or reschedule the plant would be eliminating a large tributary from that cash stream.
So, as the decriminalization of cannabis proceeds in the US and around the world, we should expect to see certain players with vested interests in its prohibition dig their heels in for a fight. Looking at the details of Cannabis Use Disorder and other cannabis related issues defined in the DSM-5 make it exceedingly difficult to come to any other conclusion. These seem like a last-ditch effort for the industries that have profited for so long to keep cannabis and other plant medicines illegal to keep the status quo. But it also shows that the walls are coming down, change is on the way, and the fight for democratically available natural medicines will one day be victorious.