Cannabis use disorder (CUD) and cannabis withdrawal syndrome (CWS) have been recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for more than a decade. Researchers have documented symptoms of anxiety, irritability, insomnia, depression, decreased appetite, intense cravings, physical symptoms, and more. Despite years of published evidence, cannabis use disorder remains one of the most underrecognized and under-resourced substance use disorders in health care. The latest findings from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health underscore that many clinicians are increasingly encountering the widespread use of cannabis, and more people are struggling with CUD than many realize.
As a physician and drug developer, I did not initially have expertise in addiction medicine. Like many clinicians, I understood that cannabis could be problematic for some individuals, but I did not yet recognize the extent to which dependence and withdrawal were affecting patients. That changed after an encounter with a patient several years ago. My husband (also a physician) and I were approached by someone who was visibly anxious, agitated, and aggressive. At the time, the behavior was out of character and perplexing. Shortly thereafter, two more individuals independently shared that they desperately wanted to stop using cannabis but simply couldn’t handle their withdrawal symptoms when they tried. Those conversations prompted me to do what physicians are trained to do: Go back to the evidence.
What surprised me wasn’t that the science existed; it was how extensive it already was. Study after study described cannabis withdrawal, dependence, and the growing prevalence of CUD. The problem wasn’t a lack of evidence. The problem was that many of us simply weren’t paying close enough attention. Like other doctors seeing patients in this same state, I almost missed the root cause of their symptoms. Physicians are trained to ask patients if they are using cannabis, but too often, the conversation ends there. We don’t routinely ask what type of cannabis they’re using, how frequently they’re using it, how potent it is, whether they’ve recently tried to stop, and whether symptoms were present prior to cannabis use.
Once I determined cannabis withdrawal could be the issue, I began reviewing the literature and found myself returning to it again and again as the landscape continued to shift. Potency was part of the story. THC concentrations are many times higher than those that informed earlier research and shaped public perceptions, and the data support a real relationship between higher-potency products and increased rates of cannabis use disorder. But potency was not the only issue.
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What has changed is a combination of factors converging at the same time. Cannabis has become far more accessible and convenient to obtain. Daily and near-daily use has increased markedly. And the prevailing public perception, reinforced by legalization, is that cannabis is safe and socially acceptable. Each of these trends on its own would be worth paying attention to. Together, they have fundamentally changed the landscape that clinicians and policymakers are navigating today, and they help explain why cannabis use disorder and cannabis withdrawal have become significant public health issues.
Clinicians often treat patients experiencing CUD and CWS for anxiety, insomnia, or depression without recognizing that these symptoms may be related to decreasing or stopping cannabis. Others never seek care because they assume what they’re experiencing is unusual, or they’ve been told that cannabis is not addictive. Some may even say it’s healthy. Clinicians may not routinely screen for cannabis withdrawal, in part because awareness remains limited, and treatment options have been extremely limited.
This is where the treatment gap became impossible to ignore. Cannabis use disorder has no FDA-approved medications, unlike opioid use disorder, which has several, and alcohol use disorder, which has multiple pharmacologic treatment options. That therapeutic gap has persisted despite the growing prevalence of CUD and the increasing potency of cannabis products.
As cannabis use continues to rise, so too will the number of individuals who experience problematic use, dependence, and withdrawal. Fortunately, researchers, clinicians, and innovators are increasingly focused on understanding cannabis use disorder and developing new approaches to care. PP-01, our investigational therapy currently in a phase 3 clinical trial, is an example of the growing scientific investment in this field, but it reflects a broader shift: recognizing cannabis use disorder as a legitimate medical condition worthy of the same rigorous research, innovation, and treatment development as other substance use disorders. That momentum reflects what patients have been saying for years: They want help, and they deserve better options.
Ginger Constantine is a physician executive.
