Cannabis-induced disorders

Last updated: September 14, 2023

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Summarytoggle arrow icon

Cannabis-induced disorders include intoxication, withdrawal, cannabinoid hyperemesis syndrome, and other cannabis-related psychiatric and medical conditions. Causative agents include various preparations made from the cannabis plant, cannabinoid extracts, and synthetic cannabinoids that are consumed by smoking, vapor inhalation, and/or oral ingestion. Clinical features of cannabis intoxication include positive neuropsychiatric effects such as euphoria and relaxation, negative neuropsychiatric effects such as anxiety, perceptual disturbances, and cognitive dysfunction, and physiologic effects including increased appetite and changes in blood pressure. Symptoms of cannabis withdrawal manifest shortly following cessation of prolonged heavy use and include irritability, anxiety, and depression. Treatment of cannabis intoxication and withdrawal is mainly supportive. Cannabis hyperemesis syndrome can occur with heavy daily use, manifests with cyclic episodes of abdominal, pain, nausea, and vomiting, and resolves with abstinence from cannabis. Acute episodes are treated with antiemetics, IV fluids, and other supportive measures.

See “Cannabis use disorder” for information on the related substance use disorder.

Overviewtoggle arrow icon

Substances [2][3]

There are a variety of preparations that may be consumed by smoking, vapor inhalation, and/or oral ingestion.

DroNABINOl is an example of a medical canNABINOid.

Mechanisms of action [3][5]

Despite extensive research, the mechanisms of action of cannabinoids are still not fully understood.

  • Tetrahydrocannabinol (THC): main psychoactive component
  • Cannabidiol (CBD): main nonpsychoactive component
    • Does not interact with CB1 and CB2 receptors
    • Reduces the psychoactivity and enhances the tolerability of THC

Overview of cannabis-induced disorders

Cannabis intoxicationtoggle arrow icon

Clinical features [2][3][12]

The clinical features of cannabis use vary depending on the type of substance and preparation, CBD-to-THC ratio, THC dose, route of ingestion, and user comorbidities. [5][13]

Neuropsychiatric effects of cannabis

  • Positive neuropsychiatric effects
    • Euphoric mood, joviality
    • Calming and relaxation
    • Increased awareness of the senses
  • Negative neuropsychiatric effects

Cannabis preparations with a high CBD-to-THC ratio are less likely to induce adverse psychiatric effects than those with a low CBD-to-THC ratio. [5][13]

Physiologic effects of cannabis

The effects of oral ingestion of THC may be delayed and unpredictable. [4]

Massive oral ingestion of cannabis products and use of synthetic cannabinoids have been associated with severe agitation, CNS depression, and seizures. [4]



DSM-V diagnostic criteria [6]

Both criteria must be fulfilled during or shortly after cannabis consumption and not be attributable to another cause.

  1. Significant neuropsychiatric effects of cannabis: behavioral and/or psychological changes such as euphoria, anxiety, or social withdrawal
  2. At least two of the following within two hours of cannabis consumption:

Urine drug screening [4]

Exposure to efavirenz, NSAIDs, pantoprazole, promethazine, or hemp can cause false positive results on urine drug screening. [3]

Treatment [2][4]

Treatment of cannabis intoxication is primarily supportive. Ensure patient safety, provide reassurance, and enable patients to rest in a quiet environment.

Use of activated charcoal following oral ingestion of cannabis products is not recommended, as the risks are considered to outweigh potential benefits. [3]

Disposition [4]

Disposition is determined on an individual basis, depending on symptoms and severity:

  • Severe CNS intoxication: Admit to the ICU.
  • Acute psychosis
  • Children with significant symptoms: Consider admission for 24 hours of observation. [4]
  • All other patients: Observe in the emergency department until signs of intoxication resolve.

Consider using the SBIRT approach to guide further counseling and treatment.

Cannabis withdrawaltoggle arrow icon

Cannabis withdrawal develops within hours to days of cessation of regular use and may persist for weeks. Manifestations and symptom severity are highly variable. [2][3]

DSM-V diagnostic criteria [6]

Both criteria must be fulfilled and not be attributable to another cause.

  1. ≥ 3 of the following features occurring within ∼ 1 week following cessation of prolonged heavy cannabis use: [6]
    • Irritability, aggression, or anger
    • Anxiety
    • Depression
    • Anorexia or weight loss
    • Restlessness
    • Sleep disturbances
    • Significant discomfort from at least one of the following: headaches, tremors, abdominal pain, fever, chills, sweating
  2. Clinically significant distress or functional impairment resulting from the above features.

Rule out potentially life-threatening withdrawal syndromes (e.g., alcohol withdrawal, benzodiazepine withdrawal), as symptoms of cannabis withdrawal are not specific. [14]

Management [14]

Cannabinoid hyperemesis syndrometoggle arrow icon

Background [15][16]

Clinical features [15][17]

  • Episodes of abdominal pain, nausea, and vomiting [17]
  • Cyclic occurrence: acute onset of episodes lasting ≤ 1 week, with asymptomatic periods between
  • Symptoms are relieved by hot showers or baths.
  • Occurrence resolves with prolonged sustained cessation of cannabis use.

Diagnosis [16][17]

Management [4][17][18]

Supportive care for acute episodes

Acute management focuses on symptomatic relief and treatment of complications of intractable vomiting.

Long-term treatment

Cannabis hyperemesis syndrome resolves with complete cessation of cannabis use.

  • Educate the patient about the etiology of their symptoms to encourage cessation.
  • Consider referral to counseling for cannabis use disorder and abstinence support.
  • Consider referring patients with polysubstance use and/or significant comorbidities to a supervised or inpatient withdrawal management setting.

Referencestoggle arrow icon

  1. $None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy.
  2. Rella JG. Recreational cannabis use: Pleasures and pitfalls. Cleve Clin J Med. 2015; 82 (11): p.765-772.doi: 10.3949/ccjm.82a.14073 . | Open in Read by QxMD
  3. Williams AR, Hill KP. Care of the Patient Using Cannabis. Ann Intern Med. 2020; 173 (9): p.ITC65-ITC80.doi: 10.7326/aitc202011030 . | Open in Read by QxMD
  4. Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review. J Pediatr. 2017; 190: p.142-152.doi: 10.1016/j.jpeds.2017.07.005 . | Open in Read by QxMD
  5. Freeman TP, Winstock AR. Examining the profile of high-potency cannabis and its association with severity of cannabis dependence. Psychol Med. 2015; 45 (15): p.3181-3189.doi: 10.1017/s0033291715001178 . | Open in Read by QxMD
  6. Devinsky O, Cilio MR, Cross H, et al. Cannabidiol: Pharmacology and potential therapeutic role in epilepsy and other neuropsychiatric disorders. Epilepsia. 2014; 55 (6): p.791-802.doi: 10.1111/epi.12631 . | Open in Read by QxMD
  7. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association ; 2013
  9. Connor JP, Stjepanović D, Budney AJ, Le Foll B, Hall WD. Clinical management of cannabis withdrawal. Addiction. 2022; 117 (7): p.2075-2095.doi: 10.1111/add.15743 . | Open in Read by QxMD
  10. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. J Med Toxicol. 2016; 13 (1): p.71-87.doi: 10.1007/s13181-016-0595-z . | Open in Read by QxMD
  11. Stanghellini V, Chan FKL, Hasler WL, et al. Gastroduodenal Disorders. Gastroenterology. 2016; 150 (6): p.1380-1392.doi: 10.1053/j.gastro.2016.02.011 . | Open in Read by QxMD
  12. Richards JR. Cannabinoid Hyperemesis Syndrome: Pathophysiology and Treatment in the Emergency Department. J Emerg Med. 2018; 54 (3): p.354-363.doi: 10.1016/j.jemermed.2017.12.010 . | Open in Read by QxMD
  13. Lapoint J, Meyer S, Yu C, et al. Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. Western Journal of Emergency Medicine. 2018; 19 (2): p.380-386.doi: 10.5811/westjem.2017.11.36368 . | Open in Read by QxMD
  14. Sazegar P. Cannabis Essentials: Tools for Clinical Practice. Am Fam Physician. 2021; 104 (6): p.598-608.
  15. Maggirwar SB, Khalsa JH. The Link between Cannabis Use, Immune System, and Viral Infections. Viruses. 2021; 13 (6): p.1099.doi: 10.3390/v13061099 . | Open in Read by QxMD
  16. Payne KS, Mazur DJ, Hotaling JM, Pastuszak AW. Cannabis and Male Fertility: A Systematic Review. J Urol. 2019; 202 (4): p.674-681.doi: 10.1097/ju.0000000000000248 . | Open in Read by QxMD
  17. Patel RS, Manocha P, Patel J, Patel R, Tankersley WE. Cannabis Use Is an Independent Predictor for Acute Myocardial Infarction Related Hospitalization in Younger Population. J Adolesc Health. 2020; 66 (1): p.79-85.doi: 10.1016/j.jadohealth.2019.07.024 . | Open in Read by QxMD
  18. Chetty K, Lavoie A, Dehghani P. A Literature Review of Cannabis and Myocardial Infarction—What Clinicians May Not Be Aware Of. CJC Open. 2021; 3 (1): p.12-21.doi: 10.1016/j.cjco.2020.09.001 . | Open in Read by QxMD

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