ICD-116C41	DISORDERS DUE TO USE OF CANNABIS Disorders due to use of cannabis
ICD-10F12	Mental and behavioural disorders due to use of cannabinoids
DSM-5-TRF12.20	Cannabis Use Disorder, Moderate or Severe

1. Definition and nosology

Cannabis Use Disorders (ICD-11: 6C41; DSM-5-TR: F12.20) — impaired control over use of THC-containing cannabis and/or harmful use. Synthetic cannabinoids are coded separately in ICD-11 (6C42).

2. History

• DSM-III (1980) — Cannabis Dependence as an official diagnosis.
• DSM-5 (2013) — “cannabis withdrawal” added as a formal category.
• 2010+ — high-potency cannabis and synthetic cannabinoids (“Spice”, “K2”) epidemic.

3. Epidemiology

• Lifetime prevalence: 7–9% cannabis users develop addiction; risk 17% in those who start in adolescence.
• Sex: higher in males.
• Comorbidity: psychosis risk, anxiety, MDD, ADHD, other substance use.

4. Aetiology and pathogenesis

• Heritability 50–60%.
• Endocannabinoid system.
• Social and cultural factors; accessibility.

5. Clinical features

• Dependence syndrome (same criteria as AUD).
• Intoxication — red eyes (conjunctival injection), tachycardia, increased appetite (“munchies”), time perception impairment, paranoid feelings.
• Severe intoxication — cannabinoid hyperemesis syndrome (vomiting syndrome with chronic use), panic, psychosis.
• Withdrawal (DSM-5 new): irritability, anxiety, sleep disturbance, decreased appetite, mood lowering, somatic complaints; onset within 24–72 hours, duration 1–2 weeks.
• Synthetic cannabinoids (‘Spice’, “K2”) — stronger, unpredictable; severe intoxication, acute psychosis, fatalities.

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR — 11 criteria (AUD structure). Unlike the single DSM-5-TR scale, ICD-11 uses three separate categories: episode of harmful use, harmful pattern of use, and dependence. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Source-specific clarifications

• NIDA — principles of cannabis use disorder.
• WHO mhGAP — assessment at the primary care level.

6.3 Diagnostic algorithm

1. Clinical interview.
2. CUDIT-R (Cannabis Use Disorders Identification Test-Revised).
3. Toxicology screening (urine THC).
4. Comorbid psychosis, anxiety, MDD.

6.4 Differential diagnosis

7. Examination and assessment

• CUDIT-R.
• Toxicology.
• Comorbidity (psychosis, anxiety, MDD).

8. Treatment

1. First-line psychosocial intervention — MI, CBT, contingency management. Evidence: Davis M.L. et al. Eval Health Prof 2015 meta-analysis.
2. No specific FDA-approved pharmacotherapy exists. Off-label: N-acetylcysteine (in adolescents Gray K.M. Am J Psychiatry 2012 RCT positive — only on a contingency management platform; in adults Gray K.M. Drug Alcohol Depend 2017 RCT negative), gabapentin.
3. Comorbid psychosis — antipsychotic; cannabis abstinence critical.
4. Synthetic cannabinoid intoxication — supportive, atypical antipsychotic if necessary.

Source-specific specifications

• NIDA — CBT and contingency management first-line.
• WHO mhGAP.

Treatment methods

1. CBT and Motivational Interviewing (MI) — Trigger management, motivation, behavior change.
2. Contingency Management — Reward for negative toxicology tests.
3. CUDIT-R — 8-item screening.
4. N-acetylcysteine (NAC) — Early positive adolescent finding did not replicate (Cochrane 2025 RR 1.17; 95% CI 0.73–1.88) — experimental; off-label.

9. Prognosis

• Significant improvement with psychosocial intervention.
• Early onset of use — poor prognosis.

10. Myths and misconceptions

Myth 1: “Cannabis is ‘natural’, not addictive”

Evidence: CUD develops in 7–9% of lifetime users; 17% in adolescents.

Myth 2: “Cannabis withdrawal syndrome does not exist”

Evidence: DSM-5 (2013) — withdrawal syndrome as an official category; irritability, sleep, appetite disturbance.

Myth 3: “Medical cannabis reduces psychosis risk”

Evidence: Marconi 2016 — THC raises psychosis risk in a dose-dependent way: about twofold at average use (OR 1.97) and about fourfold in the heaviest users (OR 3.90); preliminary evidence for CBD, not a clinical recommendation.

Myth 4: “Cannabis is not a ‘gateway drug’”

Evidence: “Gateway” concept is controversial, but sequential use pattern is statistically evident; causality has different explanations.

Myth 5: “High-THC cannabis is safer than regular cannabis”

Evidence: THC dose correlates with risk of psychosis, addiction, cognitive impairment; ‘potency creep’ over recent decades.

Myth 6: “Synthetic cannabinoids (‘Spice’) are safe”

Evidence: synthetic cannabinoids are very potent, unpredictable; acute psychosis and death cases have been recorded.

11. Sources

1. WHO. ICD-11. 6C41 Disorders due to use of cannabis. 2024.
2. APA. DSM-5-TR. 2022.
3. NIDA. Research Report on Cannabis. 2020.
4. Davis M.L. et al. Behavioral therapies for treatment-seeking cannabis users: a meta-analysis of randomized controlled trials. Eval Health Prof 2015;38(1):94–114.
5. Gray K.M. et al. A randomized placebo-controlled trial of N-acetylcysteine for cannabis use disorder in adults. Drug Alcohol Depend 2017;177:249–257.
6. Marconi A. et al. Schizophr Bull 2016;42(5):1262–1269.
7. Spiga F., Parkhouse T., Tang V.M. et al. Pharmacotherapies for cannabis use disorder. Cochrane Database Syst Rev 2025;9(9):CD008940.