Cannabis Compound Abuse Clinical Presentation

Per the DSM-IV-TR, the cannabis-related disorders are divided into 2 main categories: cannabis use disorders and cannabis-induced disorders.

When soliciting information related to marijuana use, both acutely and chronically, clinicians are advised to keep the following diagnostic criteria in mind.

Cannabis intoxication

Cannabis intoxication, a cannabis-induced disorder coded as 292.89, is defined by the DSM-IV-TR, as the following:

• Recent use of cannabis
• Clinically significant maladaptive behavioral or psychological changes (eg, impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use
• At least 2 of the following signs, developing within 2 hours of cannabis use:

  • Conjunctival injection
  • Increased appetite
  • Dry mouth
  • Tachycardia
• Symptoms not due to a general medical condition and not better accounted for by another mental disorder

Clinicians are instructed to specify if this is occurring with perceptual disturbances. This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of substance-induced psychotic disorder, with hallucinations, should be considered.

Cannabis abuse

Cannabis abuse, a cannabis use disorder coded as 305.20, is defined by the DSM-IV-TR as the following:

• A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 1 of the following, occurring within a 12-month period:

  • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspension, or expulsions from school; neglect of children or household)
  • Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine)
  • Recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct)
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical fights)
• The symptoms have never met the criteria for substance dependence for this class of substance

Cannabis dependence

Cannabis dependence, a cannabis use disorder coded as 304.30, is defined by the DSM-IV-TR as the following:

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by at least 3 of the following, occurring at any time in the same 12-month period:

• 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
• Withdrawal, as manifested by either of the following:

  • The characteristic withdrawal syndrome for the substance (Refer to Substance withdrawal.)
  • The same (or closely related) substance taken to relieve or avoid withdrawal symptoms
• The substance 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 substance use.
• A great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• 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 (eg, current marijuana use despite recognition of marijuana-induced apathy).

Clinicians are instructed to specify the following:

• With physiological dependence - Evidence of tolerance or withdrawal
• Without physiological dependence - No evidence of tolerance or withdrawal

The DSM-IV-TR defines substance withdrawal as the following:

• The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged.
• The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Compared to other illicit substances with clearly defined withdrawal states and associated symptoms, the definition of a cannabis withdrawal syndrome (CWS) has remained controversial. As no evidence is available of increasing tolerance associated with cannabis use, making the diagnosis of cannabis dependence with physiological dependence has remained controversial, if not impossible. Although prior studies have attempted to illustrate the existence of CWS, these studies have had significant limitations. And until recently there has been a dearth of any prospective studies assessing the occurrence of CWS. Recently, however, a prospective study focused on assessing the course of CWS symptoms among patients dependent on cannabis who were seeking detoxification. This study seems to support evidence of a clinically relevant CWS that the authors qualify as "only expected in a subgroup of cannabis-dependent patients."^[24]

The authors identify the following commonly observed symptoms associated with CWS:

• Anger
• Aggression
• Anxiety
• Decreased appetite
• Weight loss
• Irritability
• Restlessness
• Sleep difficulty

Although less commonly reported and occurring less frequently, the following symptoms have been reported as well:

• Depressed mood
• Stomach pain
• Physical discomfort
• Tremor
• Sweating

These symptoms are believed to occur following a 24-hour period of abstinence, peaking at day 3 following abstinence and lasting 1-2 weeks.^{[24, 25]}

Unexpectedly, the authors reported that there was a weak association between the number of endorsed DSM-IV-TR dependence criteria and the likelihood of development of CWS. The authors recommended subgrouping cannabis-dependent patients undergoing detoxification into those with no or only very mild CWS and those with moderate-to-strong CWS. Risk factors that seemed to predict which subgroup patients could be classified by, included recent cannabis intake and last amount of cannabis consumed prior to hospitalization, with patients reporting recent and more cannabis consumption before hospitalization, as more likely to report symptoms of CWS.^[24] A withdrawal scale predicated on a study of 49 cannabis-dependent subjects may have reliability in assessing the severity of cannabis withdrawal symptoms.^[26]

Cannabis intoxication delirium

Cannabis intoxication delirium, a cannabis-induced disorder coded as 292.81, is defined by the DSM-IV-TR as follows:

• Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention
• A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting established or evolving dementia
• Disturbance developing over a short period of time (usually hours to days) and tending to fluctuate during the course of the day
• Evidence from the history, physical examination, or laboratory findings either of the following:

  • The symptoms in the first 2 criterion developed during substance intoxication.
  • Medication use is etiologically related to the disturbance. (The diagnosis should be recorded as substance-induced delirium if related to medication use.)

Note: This diagnosis should be made instead of a diagnosis of substance intoxication only when the cognitive symptoms are in excess of those usually associated with the intoxication syndrome and when the symptoms are sufficiently severe enough to warrant independent clinical attention.

Cannabis-induced psychotic disorder

Cannabis-induced psychotic disorder, with delusions, a cannabis-induced disorder coded as 292.11 and cannabis-induced psychotic disorder, with hallucinations, a cannabis-induced disorder coded as 292.12, are defined by the DSM-IV-TR as follows:

• Prominent hallucinations or delusions (Note: Do not include hallucinations if the person has insight that they are substance induced.)
• Evidence from the history, physical examination, or laboratory findings of either one of the following:

  • The symptoms in the first criterion developed during, or within a month of, substance intoxication or withdrawal.
  • Medication use is etiologically related to the disturbance.
• The disturbance is not better accounted for by a psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a psychotic disorder that is not substance induced might include the following:

  • The symptoms precede the onset of the substance use (or medication use)
  • The symptoms persist for a substantial period of time (eg, about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use.
  • Other evidence suggests the existence of an independent non-substance–induced psychotic disorder (eg, a history of recurrent non-substance–related episodes).
• The disturbance does not occur exclusively during the course of a delirium.

Cannabis-induced anxiety disorder

Cannabis-induced anxiety disorder ,  categorized as a cannabis-induced disorder and coded as 292.89, is defined by the DSM-IV-TR as follows:

• Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture.
• Evidence from the history, physical examination, or laboratory findings of either of the following:

  • The symptoms in the first criterion developed during, or within 1 month of, substance intoxication or withdrawal.
  • Medication use is etiologically related to the disturbance.
• The disturbance is not better accounted for by an anxiety disorder that is not substance induced. Evidence that the symptoms are better accounted for by an anxiety disorder that is not substance induced might include the following:

  • The symptoms precede the onset of the substance use (or medication use).
  • The symptoms persist for a substantial period of time (eg, about a month) after cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use.
  • Other evidence suggests the existence of an independent non-substance–induced anxiety disorder (eg, a history of recurrent non-substance–related episodes).
• The disturbance does not occur exclusively during the course of a delirium.
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Cannabis-related disorder not otherwise specified

Cannabis-related disorder not otherwise specified, categorized as a cannabis-induced disorder and coded as 292.9, is for disorders associated with the use of cannabis that are not classifiable as one of the disorders listed above.

A thorough mental status examination is an integral component of every patient assessment. Key mental status findings associated with cannabis use, cannabis-induced and related disorders include the following:

• Mood: Acute use may be associated with feelings of euphoria, uncontrollable laughter, increased appetite, and difficulty concentrating. In chronic use or withdrawal, patients may report a depressed mood characterized by apathy, lack of motivation, irritability, loss of interest in typical activities, difficulty concentrating, and possibly isolation.
• Affect: Acutely, affect may span the spectrum from euphoric to anxious. In chronic use, affect may be constricted or flat.
• Thought process and content: As in any mental status examination, assessing the patient for the presence of suicidality or homicidality and taking appropriate action is critical. Patients may demonstrate flight of ideas, loose associations, and in some cases delusions and hallucinations.
• Cognition: In both acute and chronic use, difficulty concentrating and memory impairment are common.

Physical signs and symptoms associated with cannabis use are particularly relevant to the diagnosis of cannabis intoxication. Clinicians are advised to identify at least 2 or more of the following physical symptoms, occurring within 2 hours of cannabis use, as defined by DSM-IV-TR criteria:

• Conjunctival injection
• Increased appetite
• Dry mouth
• Tachycardia

Additionally, patients may demonstrate physical symptoms associated with cannabis withdrawal syndrome.

Other adverse physical and psychological manifestations associated with marijuana abuse are as follows:

• Sweating
• Headaches
• Restlessness
• Forgetfulness
• Visual distortions
• Lack of concentration
• Paranoia
• Mood changes
• Perceptual changes
• Feeling impersonal
• Panic disorder
• Amotivational syndrome
• Delusions
• Psychosis

Risk factors among adolescents that may increase the likelihood for marijuana abuse include the presence of comorbid substance use and environmental stressors including difficulty in school.