This document discusses cannabis use disorders and substance use disorders involving cannabis. It defines key terms like dependence, abuse, intoxication, and withdrawal. It describes the major diagnostic categories from the DSM-5 involving substance use disorders. It then discusses cannabis specifically, how it is prepared from the plant, its effects, and diagnostic criteria for cannabis intoxication, dependence, and withdrawal from the DSM-5.

1. CANNABIS & SUBSTANCE USE
DISORDERS
By Dr. Wasim

2. TERMINOLOGY
Dependence- The repeated use of a drug or
chemical substance, with or without physical
dependence.
Abuse- Use of any drug, usually by self
administration, in a manner that deviates from
approved social or medical patterns.
Misuse- Similar to abuse but usually applies to
drugs prescribed ny physicians that are not used
properly.

3. Intoxication- is used for a reversible nondependent
experience with a substance that produces
impairment.
Tolerance- defined by either of the following:
• Need for markedly increased amounts of the
substance to achieve intoxication.
• Desired effect markedly diminished effect with
continued use of the same amount of the
substance.
Cross Tolerance- Refers to the ability of one drug to
be substituted for another, each usually producing
the same physiological and psychological effects.

4. • Addiction- the repeated and increased use of a
substance, the deprivation of which gives rise to
symptoms of distress and the irresistible urge to use
the agent again and which leads to physical and
mental deterioration.

5.  There are four major diagnostic categories in the Diagnostic and
Statistical Manual of Mental Disorders, fifth edition (DSM-5):
 (1) Substance Use Disorder- the diagnostic term applied to the specific
substance abused (e.g., alcohol use disorder, opioid use disorder) that
results from the prolonged use of the substance.
 (2) Substance Intoxication- the diagnosis used to describe a syndrome
(e.g., alcohol intoxication or simple drunkenness) characterized by
specific signs and symptoms resulting from recent ingestion or
exposure to the substance.
 (3) Substance Withdrawal- the diagnosis used to describe a syndrome
(e.g., alcohol intoxication or simple drunkenness) characterized by
specific signs and symptoms resulting from recent ingestion or
exposure to the substance.
 (4) Substance-Induced Mental Disorder.

6. INTRODUCTION
• Cannabis (Cannabis sativa= Indian hemp) is the most widely used
illegal drug in the world, with an estimated 160 million users
worldwide.
• It has been used in India, China and the Middle East for
approximately 8,000 years primarily for its fiber and secondarily for
its medicinal properties.
• The female plant contains the highest concentrations of more than 60
cannabinoids that are unique to the plant. Delta-9-
tetrahydrocannabinol (THC) is the cannabinoid that is primarily
responsible for the psychoactive effects of cannabis. It is found in the
resin that covers the flowering tops and upper leaves of the female
plant.

7. PREPARATION OF CANNABIS
 Male and female plants separated.
 Female contain highest concentration of THC.
 Flowering top has highest THC concentration.
MARIJUANA: Prepared from dried flowering tops and leave
of plant.
 THC concentration 0.5- 5%.
HASHISH ( Hash or charas ): consist of dried cannabis
resin.
 Light brown to almost black color.
 THC concentration 5-8%.

8. HASH OIL: it obtained by extracting THC from Hasish or
Marijuana in oil.
 Clear pale yellow / green to brown black colour.
 THC concentration 15-30%.
GANJA: Buds and flowering top of female plant.
BHANG: Cut and dried large leaves & stem of plants

9. METHOD OF USE
INHALATION:
 Cannabis is typically smoked as marijuana in hand role, cigarettes or
joints.
 WATER PIPE is use to deliver bolus dose.
 Hashish may smoke in joints or pipe with or without tobacco.
 Hash oil is extremely potent, a few drop is applied on cigarette or
joint.
ORAL ROUTE:
 By eating hashish baked in brownies or cookies.
 In India bhang, ganja is a common form , that is use frequently at
various occasions like (Holi, Shivratri ) in which use like milk based
drink called THANDAI or typically smoked (ganja / charas) in CHILAM
or mixed with tobacco of cigarettes.
 MANOKA a dry slightly sweetish preparation consisting of bhang
paste.

10. CANNABIS EFFECTS
 Euphoria
 Feeling of well-being
 Relaxation
 Grandiosity
 Long term effects
- Panic, Anxiety
- Frank psychosis
- Depression
- Amotivational syndrome

11. Tolerance ,dependence, withdrawal
 Tolerance develops rapidly
 Withdrawal syndrome – mild
Restlessness
Irritability
Agitation
Insomnia

12. Risk Factors
1. Temperamental problems
2. Personality disorder: Antisocial (30%), obsessive-compulsive, (19%),
and paranoid (18%)
3. Externalizing & internalizing disorders: Conduct dis., ADHD
4. Academic failure
5. Tobacco smoking
6. Unstable or abusive family situation
7. Family history of a substance use disorder
8. Low socioeconomic status
9. Heritable factors (30% - 80% of the total variance)

13. DIAGNOSTIC CRITERIA DSM-5

14. INTOXICATION
A. Recent use of cannabis.
B. Clinically significant problematic behavioral or psychological changes
(e.g., impaired motor coordination, euphoria, anxiety, sensation of
slowed time, impaired judgment, social withdrawal) that developed
during, or shortly after, cannabis use.
C. Two (or more) of the following signs or symptoms developing within
2 hours of cannabis use:
 1. Conjunctival injection.
 2. Increased appetite.
 3. Dry mouth.
 4. Tachycardia.
D. The signs or symptoms are not attributable to another medical
condition and are not better explained by another mental disorder,
including intoxication with another substance.

15. Specify if:
• With perceptual disturbances: Hallucinations with intact reality
testing or auditory, visual, or tactile illusions occur in the absence of a
delirium.
Intoxication typically begins with a “high”
feeling followed by symptoms that include
euphoria with inappropriate laughter and
grandiosity, sedation, lethargy, impaired
short-term memory, difficulty carrying out
complex mental processes, impaired
judgment, distorted sensory perceptions,
impaired motor performance, and the
sensation that time is passing slowly,
anxiety, dysphoria.

16. • Dysphoria, restlessness, fear and even panic may spoil the experience
(“Bad trip”).
• Delirium occurs as a complication only rarely in neurologically intact
individuals. In such cases, symptoms of delirium, psychosis, or anxiety
seldom persist beyond 48 hrs after acute cannabis intoxication.
• If they do so, the probability is high that they are a continuation of
preexisting psychopathology.
• The acute psychotic reaction is self-limiting, generally polymorphous
and stormy.
• An acute organic state, phenomenologically indistinguishable from
delirium, may follow cannabis use (generally at a high dose - 250
micrograms/kg of THC). Altered brain amine levels and/or inhibition
of cholinergic transmission may be responsible for the same.

17. • Emotional turmoil, excitement, paranoid (unwarranted suspicion)
or hypomanic symptoms and hallucinations may predominate.
There may be driven activity (subject knows that one’s activities
are meaningless, yet is unable to control them). Hallucinations
are vivid, well formed and commonly visual.

18. DEPENDENCE
A. A problematic pattern of cannabis use leading to clinically significant
impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period:
1. Cannabis is often taken in larger amounts or over a longer period than was
intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control
cannabis use.
3. A great deal of time is spent in activities necessary to obtain cannabis, use
cannabis, or recover from its effects.
4. Craving, or a strong desire or urge to use cannabis.
5. Recurrent cannabis use resulting in a failure to fulfill major role obligations
at work, school, or home.
6. Continued cannabis use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of cannabis.
7. Important social, occupational, or recreational activities are given up or
reduced because of cannabis use.

19. 8. Recurrent cannabis use in situations in which it is physically hazardous.
9. 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.
10. Tolerance, as defined by either of the following:
 a. A need for markedly increased amounts of cannabis to achieve
intoxication or desired effect.
 b. Markedly diminished effect with continued use of the same amount of
cannabis.
11. Withdrawal, as manifested by either of the following:
 a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A
and B of the criteria set for cannabis withdrawal.
 b. Cannabis (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms.

20. Specify if:
1. In early remission: After full criteria for cannabis use disorder were
previously met, none of the criteria for cannabis use disorder have been
met for at least 3 months but for less than 12 months (with the exception
that Criterion A4, “Craving, or a strong desire or urge to use cannabis,” may
be met).
2. In sustained remission: After full criteria for cannabis use disorder were
previously met, none of the criteria for cannabis use disorder have been
met at any time during a period of 12 months or longer (with the exception
that Criterion A4, “Craving, or a strong desire or urge to use cannabis,” may
be present).

21. Specify if:
• In a controlled environment: if the individual is in an environment
where access to cannabis is restricted
Specify current severity:
1. Mild: Presence of 2–3 symptoms. 305.20 (F12.10
2. Moderate: Presence of 4–5 symptoms. 304.30 (F12.20)
3. Severe: Presence of 6 or more symptoms. 304.30 (F12.20)
• Cannabis use disorder frequently do have concurrent other mental
disorders. Careful assessment typically reveals reports of cannabis
use contributing to exacerbation of these same symptoms,

22. WITHDRAWAL
A. Cessation of cannabis use that has been heavy and prolonged (i.e., usually
daily or almost daily use over a period of at least a few months).
B. Three (or more) of the following signs and symptoms develop within 1 week
after Criterion A:
 1. Irritability, anger, or aggression.
 2. Nervousness or anxiety.
 3. Sleep difficulty (e.g., insomnia, disturbing dreams).
 4. Decreased appetite or weight loss.
 5. Restlessness.
 6. Depressed mood.
 7. At least one of the following physical symptoms causing significant
discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or
headache.

23. C. The signs or symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition
and are not better explained by another mental disorder, including
intoxication or withdrawal from another substance.
• Most symptoms have their onset within the first 24–72 hours of
cessation, peak within the first week, and last approximately 1–2
weeks.
• Sleep difficulties may last more than 30 days.
• Withdrawal tends to be more common and severe among adults (due
to more persistent, greater frequency and quantity of use and
comorbid mental disorders)

24. • Common symptoms among persons seeking help to cease
cannabis use
1. Inability to stop using
2. Feeling bad about using cannabis
3. Procrastinating & School-related problems
4. Loss of self-confidence
5. Memory loss
6. Withdrawal symptoms.

25. SIGNS OF ACUTE & CHRONIC USE
• Red eyes (conjunctival injection)
• Yellowing of finger tips (from smoking joints)
• Cannabis odor on clothing
• Burning of incense (to hide the odor)
• Chronic cough To hear
• Exaggerated craving and impulse for specific foods, sometimes at
unusual times of the day or night
To see
To smell

26. DIAGNOSTIC & CLINICAL FEATURES
INTOXICATION
INTOXICATION DELIRIUM
• Psychotic symptoms, such as delusions and hallucinations (visual and
auditory hallucinations).
CANNABIS & SCHIZOPHRENIA
• Cannabis use can precipitate schizophrenia in vulnerable individuals
(because of a personal or family history of schizophrenia) or
exacerbate its symptoms in those who have already developed the
disorder.
CANNABIS-INDUCED ANXIETY DISORDER
• Some users (mostly new users) report increased anxiety, panic, a fear
of going mad, and depression after using cannabis. More experienced
users report these effects if they use more potent forms or if they use
the oral route.

27. WITHDRAWAL AND TOLERANCE
• Probably involve changes in cannabinoid receptor functioning.
• Long half-life and complex metabolism explains that the cannabis
withdrawal syndrome is less intense than that for alcohol or the
opiates.
• These symptoms were correlated with THC dose and frequency of
use.
ANTIMOTIVATIONAL SYNDROME
• Chronic & heavy cannabis use produces an “amotivational
syndrome”. Pro social & goal-directed activities are reduced (poor
school performance and employment problems).

28. TREATMENT AND REHABILITATION
• Treatment of cannabis use rests on the same principles
as treatment of other substances of abuse abstinence
and support.
• Abstinence can be achieved through direct
interventions, such as hospitalization, or through
careful monitoring on an outpatient basis by the use of
urine drug screens, which can detect cannabis for up to
4 weeks after use.
• Support can be achieved through the use of individual,
family, and group psychotherapies.
• Education should be a cornerstone for both abstinence
and support programs.
• A patient who does not understand the intellectual
reasons for addressing a substance-abuse problem has
little motivation to stop.

29. PHARMACOLOGICAL ASPECTS:
CANNABIS INTOXICATION:
 Usually mild, self limiting, mostly does not need
pharmacological intervention.
 T/t needed in severe distressing anxiety or psychotic
symptom induced by intoxication.
 Anti psychotic (preferably atypical) for psychosis.
 Benzodiazepine in acute anxiety state.
 Propanolol has little effect.
 Duration not longer than one day. 29

30. CANNABIS WITHDRAWAL
Benzodiazepines are most commonly prescribe medication.
Dronabinol (cannabis receptor agonist) , synthetic THC (20-60
mg/day) for 7-10 days depending on duration of withdrawal
symptom.
Beclofen (40 mg/day) or Lofexidine (α2 agonist ,2.4 mg/day)
are another alternative. But not much effective.

31. CANNABIS DEPENDENCE
 No medication has been shown broadly effective for this ,
nor any approved by any regulatory authority.
 Buspiron (up to 60 mg/ day) for 12 week is 1st choice.
 Fluoxetine (20-40 mg/day) is another alternative.
 Other drug like Dronabinol, mood stabilizer tried but not
much effective.
 Emerging evidence of Baclofen(40-60 mg/day) another
reasonable T/t option.
 Rimonabent ( CB1 receptor antagonist) are marketed as
appetite suppressant but withdraw due to its psychiatric
side effect (specially sucidality).

32. PSYCHOSOCIAL ASPECT:
 Motivational enhancement therapy (MET).
 Cognitive behavior therapy (CBT).
 Contingency management (CM).
 Family and system intervention.
 Combined psychosocial treatment.
32

33. Thank You