Cannabis Use Disorder + Opioid Use Disorder - DSM-5

Diagnostic Criteria [Cannabis Use Disorder]

a problematic pattern of cannabis use, leading to clinically significant impairment / distress, shown by 2+ symptoms in a 12-mo period.

1. taken in larger amounts or over longer period than intended

2. persistent desire or unsuccessful attempts to cut down / control use

3. spending a lot of time in activities necessary to get or use cannabis, or to recover from its effects

4. craving, or strong desire / urge to use

5. recurrent use → failure to fulfill work, school, or home obligations

6. continued use despite persistent or recurrent social / interpersonal problems caused or made worse by use

7. giving up / reducing important social, occupational, or recreational activities bc of use

8. recurrent use in situations where it’s physically hazardous

9. continued use despite knowledge of persistent or recurrent physical / psychological problems likely caused or exacerbated by cannabis

10. tolerance, defined as either a) need for markedly increased amounts to achieve intoxication / desired effect, or b) markedly diminished effect w/ continued use of same amount

11. withdrawal, as shown by either a) characteristic withdrawal syndrome for cannabis or b) cannabis (or closely related substance) is taken to avoid / relieve withdrawal symptoms

Withdrawal Syndrome [Cannabis Use Disorder]

3+ symptoms within 1 week of cessation after heavy persistent usage:

1. irritability, anger, or aggression

2. nervousness or anxiety

3. sleep difficulties

4. decreased appetite / weight loss

5. restlessness

6. depressed mood

7. 1+ physical symptom causing srs discomfort: abdominal pain, shakiness / tremors, sweating, fever, chills, headache)

Specifiers [Cannabis Use Disorder]

• in early remission: none of criteria (w/ exception of craving) have been met for 3+ mos but less than 12 mos, after having previously met full criteria

• in sustained remission: none of criteria (w/ exception of craving) have been met for 12+ mos after previously meeting full criteria

• mild: 2 - 3 symptoms

• moderate: 4 - 5 symptoms

• severe: 6+ symptoms

Diagnostic Features [Cannabis Use Disorder]

• may not realise symptoms are cannabis-related, due to perception of cannabis as harmless

• lack of clarity about whether symptoms are caused by cannabis may → underreporting of symptoms

Associated Features [Cannabis Use Disorder]

• often report use to cope w/ mood, insomnia, anger, pain, or other physiological / psychological problems

• frequently have other psychological disorders

• chronic intake can → lack of motivation that looks like persistent depressive disorder

• red eyes, cannabis odor on clothes, yellowing fingertips, chronic cough, burning incense, & exaggerated craving + impulse for foods (sometimes at odd times)

Prevalence [Cannabis Use Disorder]

• 12-mo in 12 - 18 yr olds: 2.7 - 3.1%

• 12-mo in 18+: 2.5%

• most prev. in 18 - 29 bracket; lowest in 45+

• more prev. in men (3.5%) than women (1.7%) and boys (3.4%) than girls (2.8%)

• only 7 - 8% of adults with CUD got treatment within the last year

Development + Course [Cannabis Use Disorder]

• onset can happen at any age, but most common in adolescence or young adulthood

• increasing acceptability + availability of cannabis may impact development + course of CUD, & increase onset in older adults

• tends to develop over extended period of time, but may be more rapid in teens (esp. w/ conduct problems)

• use tends to increase in frequency + amount

• assoc. w/ preferences for novelty-seeking + risk taking, norm-violating or other illegal behaviours, & conduct disorder

• mild case in youth: continued use despite disapproval from peers, school, or family; can risk physical or behavioural consequences

• moderate / severe case in youth: progression to using alone / throughout the day → interferes w/ functioning + takes place of prosocial activites

• in adults: usually well-established patterns of daily use despite clear psychosocial / medical problems, w/ many cessation attempts or desire to stop

• early onset of cannabis use (<15) is good predictor of CUD, as well as other types of substance use disorders or mental health disorders during young adulthood, often concurrent w/ other problems whether internalised or externalised

Risk Factors [Cannabis Use Disorder]

• temperamental: conduct disorder or externalising / internalising disorders as kid / teen; high behavioural-disinhibition scores increase risk of early onset

• environmental: unstable / abusive family situations, cannabis use in immediate family members, childhood history of emotional / physical abuse, violent death of close family member or friend, family history of substance use disorders, ease of availability of substance, living in state w/ legalised recreational marijuana use. higher past-year risk in Black, Native American, Hispanic, & Asian American adults + adolescents

• genetic: heritable factors contribute between 30 - 80% of total variance in risk of disorder, tho not sure yet what genetic variants are involved

Sex + Gender Related Diagnostic Issues [Cannabis Use Disorder]

• women tend to have more severe withdrawal symptoms (esp. mood + gastrointestinal), which may contribute to faster telescoping (transition between first use → use disorder)

Functional Consequences [Cannabis Use Disorder]

• CUD in veterans was assoc. w/ increased risk of suicidal + non-suicidal self-injury, + increased suicide risk (esp in women)

• men w/ CUD have suicide rate of 79 per 100k person-years; women have 47 per 100k person-years

• cognitive function (esp. higher executive function) may become compromised even when not intoxicated → problems at work / school

• accidents due to potentially dangerous activities while under the influence

• reduction in goal-directed activity + decreased self-efficacy (motivational syndrome) → poor work / school performance

• cannabis-assoc. problems in social relationships

• assoc. w/ poorer life satisfaction & increased treatment + hospitalisation for mental health problems

Differential Diagnoses [Cannabis Use Disorder]

• nonproblematic use of cannabis

• cannabis intoxication, cannabis withdrawal, & cannabis-induced mental disorders

Differential Diagnosis: Nonproblematic Use of Cannabis [Cannabis Use Disorder]

majority of people who use cannabis don’t have problems related to use. 20 - 30% of users experience symptoms + consequences consistent w/ CUD.

differentiating can be hard, bc people might not attribute cannabis-related social / behavioural / psychological problems due to substance, esp. if using multiple substances. failure to acknowledge heavy cannabis use + role in assoc. problems is common in people referred to treatment by others

Differential Diagnosis: Cannabis Intoxication, Cannabis Withdrawal, & Cannabis-Induced Mental Disorders [Cannabis Use Disorder]

CUD describes problematic pattern of use that involves impaired control over use, social impairment due to use, risky use, & pharmacological symptoms; cannabis intoxication, withdrawal, & cannabis-induced mental disorders describe psychiatric symptoms that develop in the context of heavy use.

all can occur frequently in people w/ CUD — diagnoses can be given in addition to CUD

Comorbidity [Cannabis Use Disorder]

• high comorbidity w/ other substance use disorders — 9x risk of developing other substance use disorders to people without cannabis use disorder

  • cannabis considered gateway drug bc of much higher lifetime probability of using other, more risky substances

  • frequently secondary or tertiary problem for people w/ primary diagnosis of another substance use disorder

• co-occurring mental disorders: major depressive disorder, bipolar i + ii, anxiety disorders, PTSD, & personality disorders

• risk factor in schizoophrenia + other psychotic disorders — use during critical periods assoc. w/ 3x risk increase for psychosis

• respiratory disorders, cardiovascular problems, + hyperemesis syndrome (cyclical vomiting)

Diagnostic Criteria [Opioid Use Disorder]

a problematic pattern of opioid use, leading to clinically significant impairment / distress, shown by 2+ symptoms in a 12-mo period.

1. taken in larger amounts or over longer period than intended

2. persistent desire or unsuccessful attempts to cut down / control use

3. spending a lot of time in activities necessary to get or use opioids, or to recover from its effects

4. craving, or strong desire / urge to use

5. recurrent use → failure to fulfill work, school, or home obligations

6. continued use despite persistent or recurrent social / interpersonal problems caused or made worse by use

7. giving up / reducing important social, occupational, or recreational activities bc of use

8. recurrent use in situations where it’s physically hazardous

9. continued use despite knowledge of persistent or recurrent physical / psychological problems likely caused or exacerbated by opioids

10. tolerance, defined as either a) need for markedly increased amounts to achieve intoxication / desired effect, or b) markedly diminished effect w/ continued use of same amount

11. withdrawal, as shown by either a) characteristic withdrawal syndrome for opioids or b) opioids (or closely related substance) are taken to avoid / relieve withdrawal symptoms

NOTE: tolerance + withdrawal criteria are not considered to be met for those taking opioids solely under appropriate medical supervision

Withdrawal Syndrome [Opioid Use Disorder]

Cessation / reduction of opioid use that has been heavy and prolonged (i.e., several weeks or longer), or administration of an opioid antagonist after a period of opioid use, as evidenced by 3+ symptoms developing within minutes to several days:

1. dysphoric mood

2. nausea / vomiting

3. muscle aches

4. lacrimation (abnormal / excessive production of tears) or rhinorrhea (excessive discharge of mucus)

5. pupillary dilation, goosebumps, or sweating

6. diarrhea

7. yawning

8. fever

9. insomnia

Specifiers [Opioid Use Disorder]

• on maintenance therapy: patient is taking prescribed agonist + none of the criteria (except for tolerance / withdrawal) for opioid use disorder have been met for that class of medication. also applies to partial agonists, agonist / antagonists, & full antagonists

• in early remission: none of criteria (w/ exception of craving) have been met for 3+ mos but less than 12 mos, after having previously met full criteria

• in sustained remission: none of criteria (w/ exception of craving) have been met for 12+ mos after previously meeting full criteria

• mild: 2 - 3 symptoms

• moderate: 4 - 5 symptoms

• severe: 6+ symptoms

Diagnostic Features [Opioid Use Disorder]

• includes natual opioids (eg: morphine, codine), semisynthetics (eg: heroin, oxycodone) + synthetics w/ morphine-like actions (eg: methadone, fentanyl)

• can come from prescription or illicit opioids

• signs + symptoms reflecting compulsive, prolonged self-administration of opioids for purpose other than legit medical use / use in non-medical manner (eg: greatly exceeding prescribed amount)

• often develop conditioned responses to drug-related stimuli — probably contribute to relapse, are hard to get rid of, & often persist long after completed withdrawal

• most with OUD have tolerance + experience withdrawal on abrupt reduction / cessation

• tend to develop regular patterns of compulsive drug use → daily activities planned around obtaining + administrating opioids

Associated Features [Opioid Use Disorder]

• fatal or nonfatal overdoses: characterised by unconsciousness, respiratory depression, & pinpoint pupils. can occur in attempt to achieve intoxication or in absence of

• can be assoc. w/ history of drug-related crimes

• marital difficulties, unemployment, & irregular employment assoc. w/ OUD at all socioeconomic levels

Prevalence [Opioid Use Disorder]

• prescription OUD in US adults: .6 - .9%

• heroin use disorder in US adults: .1 - .3%

• prescription OUD in US teens: .4%

• heroin use disorder in US teens: essentially zero

• OUD rates higher in men than women, among young adults than older adults, & lower income / education

Development + Course [Opioid Use Disorder]

• can begin at any age

• problems assoc. w/ opioid use are most commonly seen in late teens / early 20s

• longer intrerval between first use + OUD in prescription opioids than heroin

• early use can indicate wanting relief from life stressors or psychological pain

• once OUD requiring treatment develops, can continue over many years w/ brief abstinence periods in some but longterm abstinence periods only in minority

Risk Factors [Opioid Use Disorder]

• temperamental: assoc. w/ externalising traits like novelty-seeking, impulsivity, & disinhibition; conduct disorder as kid / teen increases risk

• environmental: prescription OUD is assoc. w/ most other substance use disorders; family, peer, & social environmental factors all increase risk

• genetic: strong genetic contribution to risk but have yet to ID specific gene variants; peer factors may related to genetic predisposition for how people select their environments, including peers

Sex and Gender-Related Diagnostic Issues [Opioid Use Disorder]

women w/ OUD:

• are more likely to have started use in response to sexual abuse + violence

• are more likely to have been introduced to opioids by a partner

• tend to telescope faster

• seem to be more ill when entering treatment facilities

Functional Consequences [Opioid Use Disorder]

• heightened risk of suicide attempts + suicide

• repeated intoxications or withdrawal can be assoc. w/ severe depression that, while temporary, can be intense enough → suicide

• suicide is common cause of death in opioid users

• assoc. w/ dry mouth + nose, severe constipation, impaired visual acuity, cellulitis, abcesses, tetanus, other infections (HIV, hepatitis C, tuberculosis)

• difficulties in sexual function

• increased sensitivity to pain (hyperalgesia)

• opioid dependence in infants born to females w/ OUD

• mortality rate 6 - 20x greater than general population (overdoses, medical conditions, accidents, injuries)

Differential Diagnoses [Opioid Use Disorder]

• opioid intoxication, opioid withdrawal, & opioid-induced mental disorders

• other substance intoxication

• other withdrawal disorders

• independent mental disorders

Differential Diagnosis: Opioid Intoxication, Opioid Withdrawal, & Opioid-Induced Mental Disorders [Opioid Use Disorder]

OUD describes problematic pattern of use that involves impaired control over use, social impairment due to use, risky use, & pharmacological symptoms; opioid intoxication, withdrawal, & opioid-induced mental disorders describe psychiatric symptoms that develop in the context of heavy use.

all can occur frequently in people w/ OUD — diagnoses can be given in addition to OUD

Differential Diagnosis: Other Substance Intoxication [Opioid Use Disorder]

alcohol, sedative, hypnotic, & anxiolytic intoxication can resemble opioid intoxication. can usually be differentiated from opioid intoxication by absence of constricted pupils or lack of response to naloxone. intoxication may be due to opioid + another substance in some cases, in which case naloxone won’t reverse all sedative effects

Differential Diagnosis: Other Withdrawal Disorders [Opioid Use Disorder]

anxiety + restlessness of opioid withdrawal resemble sedative-hypnotic withdrawal. opioid withdrawl has rhinorrhea, lacrimation, & pupillary dilation, not seen in sedative-type withdrawal

dilated pupils are also seen in hallucinogen + stimulant intoxication, but will lack nausea, vomiting, diarrhea, abdominal cramps, rhinorrhea, or lacrimation

Differential Diagnosis: Independent Mental Disorders [Opioid Use Disorder]

some effects of OUD may resemble symptoms of independent mental disorders (eg: depressed mood → persistent depressive disorder). opioids are less likely to produce symptoms of mental disturbance than most other drugs of abuse

Comorbidity [Opioid Use Disorder]

• common medical comorbidities: viral (HIV + hep C) + bacterial infections, esp. among injection heroin users

• often assoc. w/ other substance use disorders (esp. tobacco, alcohol, cannabis, stimulants, & benzos)

• persistent depressive disorder + major depressive disorder, which may be opioid-induced or exacerbated by opioids

  • depressive episodes esp. common during chronic intoxication or in assoc. w/ physical or psychosocial stressors

• insomnia, esp. during withdrawal

• assoc. w/ bipolar i, PTSD, ASPD, BPD, + schizotypal personality disorder

• conduct disorder as kid / teen

• assoc. w/ serious mental illness (mental disorder other than a substance use disorder that results in serious functional impairment, substantially limiting or interfering w/ major life activities)