Running Head: Intro to CUD 1

Introduction to Cannabis Use Disorder (CUD), Medical Marijuana, and Addiction

James Michael Ryan
South University

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Abstract
This essay endeavors to briefly address the topics of Cannabis Use Disorder according to the
DSM-5, the use of cannabis for medicinal purposes, and the underlying causes of addiction,
including its causes, consequences and current standing in American society. It is the primary
thesis of the author that the very existence of a Cannabis Use Disorder speaks directly to the
existence of a universal addiction process- a consequence of emotionally deficient childhoods
and present social and political attitudes. The paper begins with an exploration of the DSM-5s
description of cannabis use disorder, followed by an investigation of recent scientific evidence
regarding medicinal uses and abusive dangers of marijuana, an appraisal of the United States
policy on drugs, and finally a discussion of addiction itself, including brain chemistry,
developmental processes, and social attitudes.

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Substance use and abuse are extremely complex issues, as are the viewpoints from which
they can be addressed. Each drug can be seen as a unique entity- with its own distinctive
pharmacological properties and neurological effects- while simultaneously being understood in
the context of a larger scientific, social and political background. Attitudes and beliefs about
drugs are very emotional, and as such they have the potential to become divisive. In order to
ensure the best outcome, it is critical for investigations into this topic to be free from ideological
determinism; unlike the current circumstances. In the United States, the situation surrounding
substance abuse is bleak; the prevalence and frequency of addictions continue to escalate, while
billions of dollars are spent on enforcement, prosecution, and punishment. As the economy
continues to hemorrhage, the United States wages a war that has proven itself unwinnable. First
during prohibition in the 1920s, and currently in the case of cannabis, the federal government
has attempted to legislate morality. Paradoxically, Americans utilize a cornucopia of drugs to
treat the entire gamut of ailments, from the common cold to chronic and terminal conditions, all
the while demonizing the self-medicating behaviors of the addict and tragically the addict
themselves. Americans have allowed fear to circumvent fact in determining the policy towards
substance abuse, responding irrationally and arbitrarily to fear-mongering politics.
Today, investigations into the effects of substance use and abuse are more important than
ever. Americans are beginning to question long-held values about drugs, and those attitudes
could potentially determine the fate of the nation. Financial stability, public health, and the very
freedom of the people are at stake. It must be understood that all drugs, whether medicinally
valuable or not, have the potential for abuse. As a result, medicinal use must be considered
alongside addiction. Drug use, whatever the type and for whatever the reason, must be
understood within the context of basic human needs; addiction, whether substance related or not,
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arises from a deficit in one or more of those needs. Investigating the nature of addiction itself
(including its incredibly high rates of comorbidity with other substance use disorders), the
process by which it develops, the impact of social and institutional policies towards it (as well as
prescribed drug use), and the relevant scientific research are essential if the goal is to treat and
eventually eliminate this growing problem. It is not an us versus them scenario, as portrayed
by government propaganda beginning in the 1930s. The problem is holistic in nature, and as
such it must be addressed in a holistic manner. The conversations of today- those had in the
medical field, research labs, and on political platforms- around the country will help shape the
future of our nation. The results are crucial not just for the drug or the drug addict, but for the
very fabric of American society.
Cannabis Use Disorder and the DSM-5
Cannabis Use Disorder is classified in the DSM-5 under the heading Substance-
Related and Addictive Disorders (2013). This section in the DSM is remarkable for a number of
reasons, not least of which is that fact that it is the most sizable portion of Section II: Diagnostic
Criteria and Codes , second only to Other Conditions That May Be a Focus of Clinical
Attention (DSM-5, 2013). It is located between Disruptive, Impulse-Control, and Conduct
Disorders and Neurocognitive Disorders, inferring, according the organizational aims of the
DSMs architects, a relationship between the three neighboring categories (DSM-5, 2013). The
DSM-5 further divides substance-related disorders into two sub-groupings: substance use
disorders and substance-induced disorders (DSM-5, 2013). Simply put, substance-induced
disorders can be viewed as the direct result of substance ingestion (in all its various forms), i.e.
intoxication, while substance abuse disorders are analogous with what has been popularly termed
addiction.
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According to the DSM-5, The essential feature of a substance use disorder is a cluster of
cognitive, behavioral, and psychological symptoms indicating that the individual continues using
the substance despite significant substance-related problems (p.483, 2013). It is also important
to recognize that the DSM-5 has incorporated the previously independent categories of
substance abuse and substance dependence under the umbrella of substance use disorder
(DSM-5, 2013). The change is congruent with the abandonment of the rigid categorical
classification system previously employed by the DSM, supplanted, in the most recent edition,
by a more dimensional approach. In addition, the DSM distinguishes between medically
appropriate dependence- dependence observed after prolonged exposure to a substance for
medical treatment- and dependence resulting from illicit use of a substance, regardless of the
substances legality (DSM-5, 2013). This distinction is important because it demonstrates the
difference between physical dependence and harmful habitual-abuse, aka addiction; a distinction
whereby substances themselves are identified as only one component of a larger phenomenon.
Interestingly the DSM does not include the word addiction in its diagnostic vocabulary
outside of the substance categorys title. It is remarkable that a term so widely utilized around the
world would be excluded from the manual charged with identifying its diagnostic criteria. The
basis for this decision appears in the DSM as follows:
Note that the word addiction is not applied as a diagnostic term in this
classification, although it is in common usage in many countries to describe
severe problems related to compulsive and habitual use of substances. The more
neutral term substance abuse disorder is used to describe the wide range of the
disorder, from a mild form to a severe state of chronically relapsing, compulsive
drug taking. Some clinicians will choose to use the word addiction to describe
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more extreme presentations, but the word is omitted from the official DSM-5
substance abuse disorder diagnostic terminology because of its uncertain
definition and its potentially negative connotation (DSM-5, p. 485, 2013).
These connotations oftentimes result in prejudice, discrimination and alienation of a
growing segment of the American population.
Cannabis use disorder and the other cannabis-related disorders include problems that are
associated with substances derived from the cannabis plant and chemically similar synthetic
compounds (DSM-5, p.510, 2013). Diagnostically, Cannabis Use Disorder (CUD) is
differentiated from other substance abuse disorders only by the substance itself. Substance Use
Disorder (SUD) is diagnosed for every drug listed in the substance-related disorder category,
except caffeine (which has no SUD category), using the same 11 criteria. In order to be
diagnosed with CUD one must exhibit clinically significant impairment or distress, as
manifested by at least two of the criteria falling under the headings of impaired control, social
impairment, risky use, and pharmacological criteria within a 12-month time-period (DSM-5,
p.509, 483, 2013). Perhaps the most telling statistic of substance-related disorders, including
Cannabis Use Disorder, is the extremely high rate of comorbidity amongst them. Estimates range
in percentage, some as high as 80% others falling as low as 25%, but the theme is clear:
substance abuse coexists with a variety of other mental disorders, from other substances, to
anxiety, depression and schizophrenia (DSM-5, 2013). Approximately 33% of adolescents with
cannabis use disorder have internalizing disorders (e.g., anxiety, depression, posttraumatic stress
disorder), and 60% have externalizing disorders (e.g., conduct disorder, attention-
deficit/hyperactivity disorder) (DSM-5, p.515, 2013). And while the process of assessing and
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diagnosing CUD mirrors the process for other substances, socially and scientifically cannabis is
easily distinguished from its counterparts.
Good Weed Science
According to CNNs chief medical correspondent, Sanjay Gupta, the research
surrounding marijuana has been disproportionately focused on the negative effects of the drug,
with nearly 90% of studies focusing on potential harm, while simultaneously dismissing the
remarkable medical uses supported by patient claims and research (Gupta, 2013). Cannabis is
proving to be a powerful medication in a variety of treatments, including the reduction of
seizures in certain cases; illustrated by the little girl with a rare form of epilepsy featured in Dr.
Guptas documentary Weed (2013). This case alone provides ample evidence of the potential
medical applications of cannabis, but the government maintains its strong stance against the
drug.
Politics makes research focusing on the positive medicinal aspects of cannabis extremely
difficult. Choosing to focus on the 9% of cannabis users who report clinically significant
impairment (relatively few compared to the roughly 23% who become addicted to heroin and
cocaine), the minor withdrawal symptoms associated with discontinued consumption by a
chronic user (nearly non-existent when compared with the side-effects of alcohol withdrawal),
and the slowed reaction-time and decreased inhibitions associated with prefrontal cortex
disruption (although they are temporary and exist in various forms for all individuals suffering
with addictions), the government continues to impede the treatments of legitimate patients
(Matte, 2010). However, there is still hope. Researchers around the globe are continuing to
investigate medicinal applications of the plant, including treatment of the side-effects of
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chemotherapy, chronic pain, anorexia, and PTSD (Gupta, 2010). The results continue to promote
the belief that marijuana has strong therapeutic value.
Sadly, marijuana has been more than criminalized in the U.S.; federally it is listed as a
schedule 1 drug, translation- it holds no medicinal value and has a very high potential. These
assertions are completely contrary to the scientific evidence (Gupta, 2013). Incredibly, even in
the face of social unrest and scientific substantiation, the federal government continues to wage
its war on cannabis. Ignoring the actions of the states, and one of their closest allies- Israel, U.S.
officials continue to emphasize decades old dogmatism focused on erroneous claims of the
catastrophic consequences of cannabis use. Fortunately, for patients and plant-lovers alike, the
science continues to defy, amaze and astound.
Scientists have begun to formulate hypothesis surrounding the cannabis plant, its two
main chemical ingredients, and their interactions with the brain. Tetrahydrocannabinol (THC)
and Cannabidiol (CBD) are falling under the microscope, as opioids and amphetamines before
them. THC, known for its hallucinogenic properties, is credited with the high that individuals
feel after consuming cannabis (Gupta, 2013). While CBD is the cannabinoid the little girl
mentioned in Dr. Guptas documentary has to thank for her miraculous reduction in seizures
(Gupta, 2013). Interestingly, cannabinoids do not exist solely in the cannabis plant. It has been
discovered that they are endogenous to virtually all mammals. As research progresses, in the
U.S. and other parts of the world, cannabinoids continue to astound; they are believed to play a
role in almost every major life function of the human body. And while documentaries like
Guptas are encouraging advancements in the fight for sound medical-marijuana policy, they
alone will not change the entrenched falsehoods that infuse most popular ideas about drugs.
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Drugs and Politics
Any discussion of relating to drugs cannot ignore the political climate from which it
arises. In the U.S., heated debates surrounding cannabis have come to the forefront of the
national political stage, most recently in the documentary aired on CNN featuring Dr. Sanjay
Gupta who not only reneged on his stance against medical marijuana, but apologized for his
contribution to misleading the American people (Gupta, 2013). A Schedule I status continues
to hamper science, but recent research of the plant and its properties has aided individuals
seeking to change that status. In the midst of this discussion, care must be taken not to discount
the reality of the dangers associated with cannabis use, especially for adolescents with
developing brains, but science and medicine must be allowed to study and utilize it for legitimate
patients.
Political activists, pharmacological interests, and healthcare professionals are all
weighing in on the Marijuana debate. Science does not support the governments strong stance
against marijuana, unmistakably illustrated in the lack of even a single case of overdose.
Contrarily, a person dies every 19 minutes from prescription drug overdoses in the U.S., an
astounding figure (Gupta, 2013). But federal policy is not limited to the demonization of weed;
all drugs and drug-users are considered enemies of America, as Dr. Gabor Matte explains in his
book In the Realm of Hungry Ghosts, to such an extent that the United States utilizes its
influence around the world to diminish harm-reduction efforts like needle-exchange programs
(2010). The ramifications of these actions are all too clear. In contrast, areas that have withstood
the onslaught and kept their programs running have reaped the rewards. Below are listed the
results of separate studies done on the United States War on Drugs and Vancouvers safe
injection facility:
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The effects of the War on Drugs as identified
by Washington States King Bar Association,
taken from Dr. Mattes In the Realm of
Hungry Ghosts p.298
The consequences of Vancouvers safe
injection site, known as Insite, taken from Dr.
Mattes In the Realm of Hungry Ghosts p.
342
the failure to reduce problematic drug
use, particularly among children
attracting the highest-risk users- those
more likely to be vulnerable to HIV
infection, overdose, public drug use,
and unsafe syringe disposal
dramatic increases in crime related to
the prohibited drugs, including
economic crimes related to addiction
and the fostering of efficient and
violent criminal enterprises that have
occupied the unregulated and
immensely profitable commercial
market made possible by drug
prohibition
reduced the number of people
injecting in public and the amount of
injecting-related litter in the Downtown
Eastside and has reduced hassles for
local businesses
skyrocketing public costs arising from
both increased drug abuse and
increased crime
reduced the overall rates of needle
sharing in the community
erosion of public health from the
spread of disease, from the concealment
and inadequate treatment of addiction,
and from undue restrictions on proper
medical treatment of pain
not increasing rates of relapse among
former drug users, nor is it a negative
influence on those seeking to stop drug
use
the abridgement of civil rights through
summary forfeitures of property,
invasions of privacy, and violations of
due process
led to increased enrollment in
detoxification programs and addiction
treatment
disproportionately adverse effects of
drug law enforcement on the poor and
persons of color
not drawn drug users from other areas
into the neighborhood
the clogging of the courts and
compromises in the effective
administration of justice, as well as a
loss of respect for the law


The research has spoken, and it thunders in the face of common beliefs and federal
policy. Not only does harm-reduction and decriminalization not increase substance abuse, but
they are proven to be the most effective social policies by far. A story that can yield far more
than a strategy for policy, the effectiveness of these intervention strategies speaks to the
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existence and nature of something deeply rooted in the psyche of the addict. Beyond the
undeniable effects of substance abuse disorders on the individual, their sphere of influence, and
the larger society as a whole, a belief that addiction is a symptom of something greater has
gained strength in professional circles. Undeniably, Substance Abuse Disorder of any type is a
diagnosable condition, requiring professional attention and, in most cases, treatment. But if the
growing argument that addiction is the symptom of something greater, made so powerfully by
clinicians such as Dr. Matte and the anecdotal evidence of addicts themselves, then it may be
necessary to completely reconfigure the popular understanding of addiction, in all its various
forms.
Substance Abuse Disorders and Addiction
The substance abuse disorder category is the home of 10 separate classes of drugs. In the
DSM-5 the particular effects of each drug are indicated by the independent categories, while the
universal effects of substances on the brain are represented in the form of shared diagnostic
criterion. As with the other substance abuse disorders, Cannabis Use Disorder (CUD) is
diagnosed along a spectrum; CUD can exist in mild, moderate and severe states. Severe
substance abuse disorder, referred to by many as addiction, is inextricably linked to
abnormalities in the major chemical systems in the brain. Even mild substance abuse,
categorized by the presence of no more than 3 of the 11 diagnostic criteria, can alter brain
chemistry and insinuate the existence of a deeper issue because the areas of the brain associated
closely with addiction are also responsible for many of the bodys survival functions. Dr. Gabor
Matte`, in his book In the Realm of Hungry Ghosts, explains it this way:
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There is no addiction center in the brain, no circuits designated strictly for
addictive purposes. The brain systems involved in addiction are among the key
organizers and motivators of human being emotional life and behavior- hence
addictions powerful hold on human beings. addiction inevitably involves both
opioid and dopamine circuitry. The dopamine system is most active during the
initiation and establishment of drug intake and other addictive behaviors. It is the
key to reinforcing all patterns of all drugs of abuse- alcohol, stimulants, opioids,
nicotine, and cannabis. Desire, wanting, and craving are all incentive feelings, so
it is easy to see why dopamine is central to non-drug related addictions, too. On
the other hand, opioids- innate or external- are more responsible for the pleasure-
reward aspects of addiction (Matte, p.158, 171, 2010).
Along with opioid and dopamine pathways, hard-core drug abuse has been linked to
decreased inhibitory regulation in the brains prefrontal cortex resulting in problematic behaviors
(DSM-5, 2013). The inability to demonstrate self-control and self-regulation are the result of
abnormal brain development (Matte`, 2010). While ample evidence exists to support the claim
that drug abuse can negatively affect the chemistry of the brain, an increasing numbers of studies
support the hypothesis that addiction involves brain development prior to any contact with the
substance. The three dominant brain systems in addiction- the opioid attachment-reward
system, the dopamine-based incentive-motivation apparatus, and the self-regulation areas of the
prefrontal cortex- are all exquisitely fine-tuned by the environment. To varying degrees, in all
addicted persons these systems are out of kilter (Matte`, 2010). The effects of irregular
development in these areas of the brain support the claim that a proclivity to drug-abuse exists
prior to contact with any substance (DSM-5, 2013). Studies of drug addicts repeatedly find
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extraordinarily high percentages of childhood trauma of various sorts, including physical, sexual,
and emotional abuse (Matte`, 2010). The correlation of addiction and abuse is powerful and
telling. The research supports the hypothesis that abuse- of any type, including neglect- results in
the underdevelopment of the victims brain, increasing their chances of substance abuse
disorders exponentially (Matte, 2010). Continually studies suggest, a single incidence of abuse in
the formative years of a childs life can nearly triple their susceptibility to substance abuse later
in life (Matte`, 2010). The systems subverted by addiction- the dopamine and opioid circuits,
the limbic or emotional brain, the stress apparatus and the impulse-control areas of the cortex-
just cannot develop normally in such circumstances (Matte`, 2010).
The tragic results of these brain abnormalities wander through the dark allies of every
major North American city. Following their traumatic, oftentimes horrific childhoods, addicts
grow-up. They are left to handle their pain on their own, not only abandoned by the larger
society, but denigrated, vilified and hunted. Their plight is something truly devastating, to both
the individuals and the society they live in. They suffer from brain aliments that render their
ability to make the right choices suspect in even the most compassionate of circumstances, and
they are punished for not being able to just say no in what is, for many of us, truly
unimaginable desperation. Not only do they feel alone, they are alone; a problem continually
overlooked and neglected. The time has come to take ownership as a society; as individuals
operating within a set governmental framework, we must acknowledge our role in perpetuating
our own demise, one forgotten soul at a time.



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References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. Arlington, VA, American Psychiatric Association, 2013.
Gupta, S. (Producer) (2013). Weed [Web]. Retrieved from
https://www.youtube.com/watch?v=Z3IMfIQ_K6U
Matte M.D., G. (2010). In the realm of hungry ghosts: Close encounters with addiction. Berkley,
California: North Atlantic Books.