Cannabis use disorder (CUD), also known as marijuana use disorder, is defined by compulsive use of cannabis despite adverse consequences, difficulty controlling use, and withdrawal symptoms. The increase in cannabis use, particularly of high-potency products and cannabis use disorder (CUD), is a growing health care concern. In 2021, 14.2 million people in the United States of age 12 older had CUD in the past year. Nine percent of all cannabis users develop CUD. The risk nearly doubles to 17% among those who began using in adolescence and can be as high as 30% among daily users.

First, the Good News

Adolescent drug use continued to drop in 2024, extending historically significant decreases during the 2020 pandemic. The number of students abstaining from drugs reached record low levels in 2024. The good news is, for 10^th and 12th graders, past 12-month use levels were lowest in three decades. Richard Miech, Ph.D., who led the Monitoring the Future Study surveying eighth-, 10th-, and 12th-grade students in the United States, was surprised by this lower rate. He said, “The percentage of students who abstained from use of these drugs in 2024 was 67% in 12th grade (compared to 53% in 2017 when first measured), 80% in 10th grade (compared to 69% in 2017), and 90% in eighth grade (compared to 87% in 2017). Increases saying no to drugs and alcohol were clear and statistically significant in 12th and 10th grades.”

Cannabis Use Disorder Diagnosis in the DSM

Cannabis use disorder (CUD) is diagnosed based on criteria in the DSM-5. Symptoms fall into four broad categories: impaired control, social impairment, risky use, and pharmacological criteria.

Among adults, CUD rates have risen significantly as modern cannabis products (concentrates, edibles) gained market share. High-potency products may contain THC concentrations as high as 90% and contribute to CUD in teens and adults. High-dose THC smoking, called dabbing, has surged in popularity, especially among youths.

The risk of developing CUD increases among youth using cannabis at least weekly, with highest prevalence among daily users. Young people using in the morning (e.g., “eye-opener,” “wake and bake”) may be identifiable and at risk for CUD.

Cannabis Use-Related Emergency & Treatment Admissions

Cannabis-related emergency department (ED) visits are rising. Most cannabis-related ED visits occur in people 15 to 24 years old. Reasons for visits included cannabis-induced psychosis, intoxication, and unintentional ingestion.

Cannabinoid Overdose & Hyperemesis Syndrome (CHS)

High-THC cannabis concentrates, including shatter, butter, wax, and oils used for dabbing and producing vaping cartridges and infused joints, are exposing the user to very high THC levels—about 10 times what we used to consider “highly potent” smokable cannabis. This new era of high-dose cannabis self-administration is causing teens to go to emergency rooms with seizures, sweaty cyclical vomiting, disorientation, or psychosis. Some call it a cannabis overdose or a “green out,” but unlike an opioid overdose, we do not have a reversal agent like Naloxone.

Cannabinoid hyperemesis syndrome (CHS) is a condition of concern. CHS causes cyclic episodes of severe nausea, vomiting, and abdominal pain, often leading to dehydration and emergency room visits. Exact numbers are elusive because there is no diagnostic code for CHS.

ER management involves hydration and antiemetics, though traditional antiemetics like ondansetron may be less effective. Symptoms sometimes improve with hot showers or baths, a unique diagnostic clue. CHS symptoms progress through phases: mild nausea, severe vomiting and abdominal pain, and recovery after cessation of cannabis use.

Droperidol, an older medication, seems effective stopping vomiting; however, ending cannabis use is the only definitive treatment. Denial that marijuana is to blame for CHS and CUD leads to an 80% relapse rate of symptoms as patients resume their cannabis use.

Cannabis Use Disorder Treatment

About 15.8 million people in the U.S. meet criteria for cannabis use disorder (CUD). Thomas McLellan, deputy “drug czar” in the Obama Administration, notes, “the great majority of cannabis-related problems affect those ages 12-25, which means the problems will have a longer duration.”

The American Society of Addiction Medicine (ASAM) developed guidelines for opioid and stimulant use disorders, but comprehensive guidelines for cannabis use disorder are unavailable. Cannabis users with another SUD, mental health disorders, or family history of substance use disorders are at higher risk for CUD.

There are no FDA-approved pharmacological treatments for CUD. Patients with CUD complain about cognitive impairments even when not actively intoxicated, difficulty sleeping, and hot flashes as well as cough, irritability, restlessness, depression, memory deficits, and attention problems. Some patients with CUD have been reported to have psychosis during cannabis discontinuation, not just when intoxicated.

The disorder has adverse health, school, work, family, and social consequences. Treatment often focuses on behavioral interventions and supportive care.

Clinical Trials

Gabapentin, an anticonvulsant, has shown some effectiveness in reducing cannabis use and withdrawal symptoms. Oxytocin, a neuropeptide, is being explored for its potential to mitigate withdrawal and relapse by modulating social and stress responses. Trials are also investigating dronabinol (a synthetic THC) for cannabis withdrawal.

CBD is being studied as a treatment for CUD due to its modulatory effects on the endocannabinoid system and ability to reduce cravings. A Phase 2a trial showed promise, suggesting higher doses of CBD may reduce cannabis use and dependence symptoms.

Fatty acid amide hydrolase (FAAH) inhibitors aim to modulate the endocannabinoid system by increasing anandamide, the brain’s cannabinoidlevels. One study demonstrated a specific FAAH inhibitor, PF-04457845, reduced withdrawal symptoms with CUD, but further trials are needed.

N-acetylcysteine (NAC), a medication and dietary supplement with anti-inflammatory and antioxidant properties, has been studied for its role in restoring glutamate balance in the brain. Preliminary findings suggest NAC combined with psychosocial treatment may improve cannabis abstinence outcomes in youth ages 15-21 years.

Patients treated with semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA) treating type 2 diabetes (T2D) and weight management, have reported reduced desires to drink and smoke. Preliminary evidence of beneficial effects for GLP-1 in CUD came from a retrospective cohort study of electronic health records (EHRs) from the TriNetX Analytics Network.

Cannabis Use in Parents Matters

“Parents need to recognize their use matters,” said Stacey J. T. Hust, Ph.D., professor at WSU and lead author of a recent study. The WSU team surveyed 276 adolescents aged 13-17 in Washington state about their perceptions of parental cannabis use, closeness to parents, and level of parental monitoring.

Teens who think their parents use cannabis feel more favorably toward the drug and express intentions to try it. Researchers found parental monitoring can be a robust protective factor against underage cannabis use, particularly for boys. Researchers emphasize open, honest conversations about cannabis, combined with clear boundaries, can mitigate its appeal to teens.

Research shows prevalence of CUD is higher in states with recreational cannabis laws. For example, heavy use among teens and young adults—a key risk factor for CUD—is more common in states where cannabis is legal.

Conclusion

Fewer adolescents are using cannabis, which is very good since adolescents are susceptible to the harmful effects of THC due to ongoing brain development. However, some teens have CUD and others are at risk by using high-potency cannabis products. Prevention strategies and early interventions are critical to mitigating effects.

Currently, there are no FDA-approved pharmacological treatments for CUD, cannabis overdose, cannabis withdrawal syndrome, craving, and preventing CUD relapse. For example, GLP-1s used for obesity (think Ozempic) seem to help, but controlled trials are needed.