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Cannabis use and cannabis use disorder

Abstract

Cannabis use disorder (CUD) is an underappreciated risk of using cannabis that affects ~10% of the 193 million cannabis users worldwide. The individual and public health burdens are less than those of other forms of drug use, but CUD accounts for a substantial proportion of persons seeking treatment for drug use disorders owing to the high global prevalence of cannabis use. Cognitive behavioural therapy, motivational enhancement therapy and contingency management can substantially reduce cannabis use and cannabis-related problems, but enduring abstinence is not a common outcome. No pharmacotherapies have been approved for cannabis use or CUD, although a number of drug classes (such as cannabinoid agonists) have shown promise and require more rigorous evaluation. Treatment of cannabis use and CUD is often complicated by comorbid mental health and other substance use disorders. The legalization of non-medical cannabis use in some high-income countries may increase the prevalence of CUD by making more potent cannabis products more readily available at a lower price. States that legalize medical and non-medical cannabis use should inform users about the risks of CUD and provide information on how to obtain assistance if they develop cannabis-related mental and/or physical health problems.

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Fig. 1: Distribution of cannabinoid CB1 and CB2 receptors.
Fig. 2: CB1 receptor signalling.
Fig. 3: The reward circuitry.
Fig. 4: PET imaging of CB1 receptors and FAAH.
Fig. 5: A multifactorial model for cannabis use disorders.
Fig. 6: The hierarchy of substance use disorders across diagnostic systems.

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Acknowledgements

The Australian National Centre for Youth Substance Use Research (J.P.C., W.D.H., D.S.) is supported by funding from the Australian Government provided under the Commonwealth Drug and Alcohol Program grant. B.L.F. is supported by a clinician-scientist award from the Department of Family and Community Medicine at the University of Toronto and by the Centre for Addiction and Mental Health. E.H. has received research grants from the German Federal Ministry of Health and the European Monitoring Centre for Drugs and Drug Addiction. A.J.B. is supported in part by US National Institute on Drug Abuse (NIDA) grants P30DA029926, T32DA037202, R01DA050032. The funding bodies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript or the decision to submit the paper for publication.

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Introduction (J.P.C. and W.D.H.); Epidemiology (J.P.C., W.D.H., E.H. and D.S.); Mechanisms/pathophysiology (B.L.F., E.H. and J.P.C.); Diagnosis, screening and prevention (J.P.C., A.J.B., E.H. and B.L.F.); Management (J.P.C., A.J.B. and B.L.F.); Quality of life (D.S.); Outlook (J.P.C., B.L.F., W.H., A.J.B., E.H. and D.S.). All authors contributed substantially to the review and editing of the manuscript.

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Correspondence to Jason P. Connor.

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Competing interests

B.L.F. has obtained funding from Pfizer (GRAND Awards, including salary support) for investigator-initiated projects. B.L.F. has received in-kind donation of cannabis product from Aurora and medication donation from Pfizer and Bioprojet and was provided a coil for TMS study from Brainsway. B.L.F. has also obtained industry funding from Canopy (through research grants handled by CAMH or University of Toronto), Bioprojet, ACS and Alkermes, and has received in kind donations of nabiximols from GW Pharma for past studies funded by CIHR and NIH. E.H. receives fees for trainings on treatment of CUD from clinics and public health organizations and royalties for a treatment manual for cannabis use disorders from Hogrefe Publishing (Germany). All other authors declare no competing interests.

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Nature Reviews Disease Primers thanks L. Greenwood, who co-reviewed with N. Solowij, T. Freeman, R. Gonzalez, K. Gray and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Connor, J.P., Stjepanović, D., Le Foll, B. et al. Cannabis use and cannabis use disorder. Nat Rev Dis Primers 7, 16 (2021). https://doi.org/10.1038/s41572-021-00247-4

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