Cannabis Use Disorder: Reefer Madness or Real?
By Stacey Marie Kerr MD, Hawaiian Ethos Medical Advisor
There are those who are convinced that cannabis use disorder is a made-up diagnosis created by the same people who brought us Reefer Madness. They claim that it simply does not exist except in the minds of people who have never tried weed!
Then there are those who are convinced that cannabis is a dangerous illicit drug, and any kind of use is abuse. They feel that medical cannabis patients who claim to be using cannabis for relief are just using that as an excuse to get high.
Somewhere in between these two points of view lies the truth.
The official definition
Cannabis use disorder, a cannabis-related disorder coded as 305.20 for mild or 304.30 for moderate or severe, is defined by DSM-5 as the following:
A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:
Cannabis is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.
A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
Craving, or a strong desire or urge to use cannabis.
Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.
Important social, occupational, or recreational activities are given up or reduced because of cannabis use.
Recurrent cannabis use in situations in which it is physically hazardous.
Cannabis 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 cannabis.
Tolerance, as defined by either a (1) need for markedly increased cannabis to achieve intoxication or desired effect or (2) markedly diminished effect with continued use of the same amount of the substance.
Withdrawal, as manifested by either (1) the characteristic withdrawal syndrome for cannabis or (2) cannabis is taken to relieve or avoid withdrawal symptoms
definitions: easier stated than applied
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has an ‘official’ definition for Cannabis Use Disorder (see above). These listed symptoms used by doctors reflect dependency and an inability to control the use of an intoxicating substance. Cannabis abuse can be similar to the abuse of any substance humans come to depend on to handle the stress of life.
There are cannabis users who inhale cannabis several times a day every day, and they are fully functional members of society. You would never suspect they are intoxicated. And in truth, they may not be. They may be so accustomed to the medicine that they no longer get high, and they may function best that way.
Consider: John is a married man with two children. His habit is to smoke a joint in the morning out on the back deck of his home, then go in and make breakfast for the kids. Once the kids are off to school, he takes a break to smoke another and then goes off to work in his home office. He continues this pattern of work and smoke-breaks for the rest of the day, and his final joint before bed might be the 4th or 5th of the day. He earns a good living and takes good care of his family, doing his share of housework and childcare. But he and his wife have not been intimate for six years. She may join him for an evening smoke break after the kids are in bed, but otherwise she does not use cannabis.
Is this abuse? If she asks him to cut back or take a cannabis vacation, and he refuses, is it then considered a use disorder?
Which of these are examples of Cannabis Use Disorder? (Choose all that apply)
A. A 17-year-old boy who spends hours smoking cannabis and playing video games.
B. A 44-year-old married father who smokes cannabis first thing in the morning every day.
C. A 27-year-old pregnant woman who vaporizes cannabis to help her with morning sickness.
D. A recently retired 67-year-old who spends most days smoking cannabis and watching reality TV shows.
If you are a bit confused, you’re not alone. In many cases, defining cannabis use disorder is dependent on the observer and that person’s attitude about cannabis. The observer could be a health care provider, a friend, or a family member.
no easy answers
Let’s look at possible answers to the pop quiz. Often times the difference between medical use and abuse come down to age and lifestyle choices.
A. The 17-year-old who plays video games all day long is probably abusing cannabis. The teenage brain is not yet fully developed and there is good evidence that heavy use while young may be reflective of lifestyle choices that could lead to long-term problems.  Without a clear medical diagnosis (such as a seizure disorder or Attention Deficit Disorder), his cannabis use may isolate him or prevent him from exploring other growth opportunities in his young life. Of particular concern is the fact that there may be an underlying reason for this pattern of behavior, one that should be identified and addressed.
B. A 44-year-old who smokes before getting up in the morning may or may not be abuse. This depends on the situation and would require more information to evaluate. Does he have a clear and specific reason for using before getting up? If so, what is that reason? Can he verbalize it clearly? Once he is up, does he function well throughout the day? Is he able to interact appropriately with his family? We simply do not know enough about his situation to evaluate whether it is abuse or not, but the questions could be asked.
C. A pregnant 27-year-old who uses cannabis would be considered by many to be abusive. But some would say that this is appropriate use of the medicine, if it is effective and used in small amounts just adequate for her needs. Is she using it for a legitimate medical need, like acute morning sickness? Does she really need it for stress relief, or are there lifestyle changes she could make to address the root cause of her stress? A nonjudgmental conversation that helps problem solve while informing her of proven science could allow her to make her own best choice. For more information about cannabis and pregnancy, click here.
Note: cannabis should be stored in a child-proof location to make sure any children in the house are not accidentally exposed.
D. The retired 67-year-old may be considered as having a use disorder if he is using cannabis to self-medicate in ways that are not supportive of his well-being. His situation requires more consideration and an evaluation for common health problems faced by older adults. He may be self-medicating for depression, chronic pain, or suffering from a sleep disorder. Discussing his reasons for using cannabis to self-medicate could lead to more effective methods of addressing his needs. If he is perfectly content to spend his days this way, is not ignoring a spouse or other family members, and is physically healthy, then there is little harm done. However, should he discontinue constant use, or even take a cannabis vacation, he may discover other activities that he enjoys.
Lastly, what about John—the married man who seems very functional but uses cannabis from dawn to dark? Does he have clear reasons for his use, or is it simply his habit to smoke joints all day? If he is willing to take a cannabis vacation and let his receptors reset, he could find out. Has his wife asked him to take a break from smoking, and has he refused? If his partner is missing the intimacy, and cannabis is getting in the way, a cannabis vacation could uncover problems that are otherwise masked by his use of the herb. But certainly, if he considers his desire for cannabis more important than taking care of his primary relationship, then it could be considered a use disorder.
Ally, crutch, or problem?
Anything we use to help us cope with the challenges of life can go from being an ally to a crutch and may even have the potential of becoming a problem in and of itself. An ally supports us in being healthier, happier, and living the productive life we want to live. A crutch may seem like an ally for a time, until we realize that we have become dependent on it. That dependency may be causing harm, even though it seems like it helps in the moment. Something becomes a problem when it becomes clear that it is causing harm, but we feel we can’t stop, even for a week or two.
Even something as healthy as exercise can become compulsive and therefore a problem. In the case of cannabis, each person’s use needs be evaluated within the context of that individual’s family and work, as well as their emotional, mental, and physical well-being.
As we continue to learn more about the endocannabinoid system, we realize that we are just beginning to understand the powerful effects of cannabis throughout the body. This is even more true considering the high concentration THC strains and extracts available today. This medicine, as with all medicines, deserves respect.
If you suspect you have a use disorder or if someone in your life has brought up the issue with you, see if you can take a break from using cannabis for a week or two. You may have some symptoms as your body resets its cannabinoid receptors and you become clearer about your reasons for using this medicine. Gaining this perspective can help you find a healthy balance in your relationship with cannabis, and yourself.
These questions may be helpful in evaluating possible cannabis use disorder:
Do you use cannabis for a specific symptom? If so, what is it?
Do you consciously identify a specific reason for using cannabis each time you dose?
Do you know the dose of cannabis you use?
How much money do you spend on cannabis each month and what percentage of your budget is that amount?
Do you ever take a cannabis holiday to re-sensitize your receptors?
Has a family member ever asked you to stop using cannabis?
Has your use of cannabis affected your work life?
Have you ever, in any large or small way, considered cutting back on your use?