1. Basics and pharmacology
   • Cannabis preparations: bhang, ganja, charas/hashish, marijuana, concentrates, synthetic cannabinoids
   • THC, CBD, endocannabinoid system, CB1/CB2 receptors, pharmacokinetics, potency and route-related effects
2. Epidemiology and risk factors
   • Global and Indian context
   • Early initiation, male sex, peer use, availability/high-potency products, conduct disorder, trauma, family history, comorbid psychiatric illness, tobacco and other substance use
3. Clinical presentations
   • Acute intoxication
   • Cannabis-induced anxiety/panic, psychosis, delirium, mood and sleep disorders
   • Amotivational/cognitive effects
   • Cannabis hyperemesis syndrome
   • Respiratory, cardiovascular and reproductive effects
   • Cannabis use disorder
4. Diagnosis and assessment
   • DSM-5-TR/ICD framework
   • History, mental status examination, screening tools, urine testing and its limitations
   • Differential diagnosis, especially primary psychosis versus cannabis-induced psychosis
5. Intoxication, withdrawal and emergencies
   • Diagnostic features, time course, complications
   • Management of panic, agitation, psychosis, delirium and synthetic-cannabinoid toxicity
   • Cannabis withdrawal syndrome
6. Treatment of cannabis use disorder
   • Brief intervention and motivational interviewing
   • CBT, relapse-prevention therapy, contingency management, family interventions
   • Management of comorbidity
   • Pharmacotherapy: no approved specific medication; evidence and limits for agents studied
7. Relapse prevention and rehabilitation
   • Trigger identification, craving management, lapse versus relapse, urine-monitoring strategy, recovery supports, family work and follow-up plan
8. Special populations and forensic/legal issues
   • Adolescents, pregnancy/lactation, psychosis vulnerability, bipolar disorder, medical cannabis
   • India-specific legal framing and NDPS concepts relevant to psychiatry
9. Digital tools/apps
   • Use as adjuncts for self-monitoring, craving logs, CBT skills and appointment support, not as a replacement for clinician-led care. No cannabis-specific app has sufficient evidence to be prescribed as a standalone treatment.

• A. Cannabis use disorder: complete long answer
• B. Intoxication, withdrawal and emergency management
• C. Cannabis-induced psychosis and differential from schizophrenia
• D. Treatment and relapse prevention
• E. Epidemiology, pharmacology and complications

Cannabis: MD Psychiatry Theory Notes

1. Introduction and definition

Common Indian preparations

2. Epidemiology

India

Risk of developing cannabis use disorder

• Around 1 in 10 people who ever use cannabis may develop dependence/CUD.
• Risk is substantially higher, often quoted as around 1 in 3, among regular or near-daily users.
• Earlier initiation and more frequent use increase risk.

Factors associated with cannabis use and CUD

A. Individual factors

• Early initiation, especially adolescence
• Male sex
• Impulsivity, sensation seeking, novelty seeking
• Poor coping skills
• Conduct disorder, oppositional defiant disorder, ADHD
• Depression, anxiety disorders, PTSD
• Bipolar disorder
• Psychotic-spectrum vulnerability
• Childhood trauma/adversity
• Poor academic performance and school dropout
• Prior use of tobacco, alcohol or other psychoactive substances

B. Family and social factors

• Parental cannabis or other substance use
• Family history of SUD
• Poor parental monitoring, adverse parent-child relationship
• Peer substance use
• Family conflict, low social support
• Availability, low perceived risk, permissive attitudes
• Urban exposure, social marginalization in some settings

C. Drug-related factors

• High THC concentration
• Daily or near-daily use
• Use of cannabis concentrates
• Edible consumption, because delayed onset can lead to repeated dosing
• Co-use with alcohol or tobacco
• Synthetic cannabinoid exposure

D. Psychosis-specific risk factors

• Frequent or daily use
• High-potency THC products
• Early adolescent exposure
• Family history of schizophrenia/psychosis
• Prior attenuated psychotic symptoms
• Genetic/developmental vulnerability
• Continued use after a first psychotic episode

3. Pharmacology and neurobiology

Active constituents

THC

• Primary intoxicating constituent.
• Partial agonist at CB1 and CB2 receptors.
• Responsible for euphoria, altered perception, impairment of memory/attention, anxiety, paranoia, psychotic symptoms, tachycardia and appetite stimulation.

CBD

• Has low affinity for CB1/CB2 receptors.
• Has multiple proposed actions including serotonergic, TRPV1 and other pathways.
• Not intoxicating in the usual sense.
• The presence of CBD does not make high-THC cannabis safe.
• Pharmaceutical CBD has restricted, specific medical uses in certain epilepsy syndromes, not for routine treatment of CUD.

Endocannabinoid system

Endocannabinoids

• Anandamide
• 2-arachidonoylglycerol (2-AG)

Receptors

CB1 receptors

• Cerebral cortex
• Hippocampus
• Basal ganglia
• Cerebellum
• Amygdala
• Hypothalamus
• Reward circuitry

• Impaired memory and attention
• Altered time perception
• Motor incoordination
• Increased appetite
• Reward/reinforcement
• Anxiety/paranoia and psychosis in susceptible individuals

CB2 receptors

• Immune cells
• Peripheral tissues
• Microglia and some CNS locations

Neurochemical effects

• GABA
• Glutamate
• Dopamine
• Noradrenaline
• Acetylcholine

4. Pharmacokinetics and routes of use

Important points

• THC is highly lipid soluble.
• It is metabolized hepatically, mainly to 11-hydroxy-THC, an active metabolite that may contribute substantially to oral cannabis intoxication.
• Urine cannabinoid tests may remain positive long after acute intoxication, especially in regular users.
• Therefore, a positive urine test indicates prior exposure, not necessarily current intoxication or impairment.

5. Acute cannabis intoxication

DSM-5-TR diagnostic framework

A. Recent use of cannabis.

B. Clinically significant problematic behavioral or psychological changes developing during or shortly after use, such as:

• Euphoria
• Impaired judgment
• Impaired motor coordination
• Anxiety
• Suspiciousness/paranoid ideas
• Social withdrawal
• Sensation of slowed time
• Impaired attention

C. At least two of the following signs developing within two hours of use:

1. Conjunctival injection
2. Increased appetite
3. Dry mouth
4. Tachycardia

D. Symptoms are not due to another medical condition or better explained by another mental disorder or substance.

Clinical features

Subjective or psychological features

• Euphoria, relaxation, laughter
• Altered perception of time, usually subjective slowing of time
• Intensification of sensory perception
• Increased appreciation of music, colors and food
• Impaired short-term memory
• Impaired attention and concentration
• Impaired judgment
• Loosening of associations in high doses
• Anxiety, fear, panic attacks
• Suspiciousness or transient paranoid ideation
• Depersonalization
• Derealization
• Illusions; occasionally hallucinations at high doses

Physical features

• Conjunctival injection
• Dry mouth
• Tachycardia and palpitations
• Increased appetite
• Impaired coordination
• Slowed reaction time
• Ataxia
• Postural hypotension, occasionally
• Tremulousness, especially with anxiety
• Nausea/vomiting in some patients

Cognitive and psychomotor effects

• Impaired recent memory
• Reduced sustained attention
• Impaired reaction time
• Impaired complex psychomotor performance
• Driving impairment
• Additive impairment when combined with alcohol

Intoxication delirium

• Disturbance in attention and awareness
• Fluctuating consciousness
• Disorientation
• Marked cognitive impairment
• Perceptual disturbance
• Acute onset in close temporal relation to intoxication

• Very high THC doses
• Edibles/concentrates
• Synthetic cannabinoids
• Children and older persons
• Co-ingestion
• Medical illness or dehydration

6. Adverse psychiatric and medical effects

A. Acute psychiatric complications

• Anxiety and panic attacks
• Paranoid ideation
• Depersonalization/derealization
• Acute psychosis
• Delirium
• Agitation and aggression, particularly with fear, paranoia or synthetic cannabinoids
• Suicidal behavior in the context of severe intoxication, mood disorder or psychosis

B. Cognitive effects

• Attention
• Working memory
• Short-term recall
• Learning
• Reaction time
• Coordination
• Executive functioning

C. Amotivational syndrome

• Apathy
• Reduced drive
• Reduced initiative
• Loss of interest in work or studies
• Social withdrawal
• Diminished goal-directed activity
• Poor academic or occupational performance

D. Respiratory effects

• Chronic cough
• Sputum production
• Wheeze
• Chronic bronchitic symptoms
• Airway irritation

E. Cardiovascular effects

• Tachycardia
• Palpitations
• Orthostatic hypotension
• Rare ischemic or arrhythmic complications, especially in persons with underlying cardiovascular disease or with high doses

F. Reproductive and pregnancy concerns

G. Cannabis hyperemesis syndrome

• Recurrent severe nausea and vomiting
• Abdominal pain
• Typically chronic/heavy cannabis use
• Temporary relief with hot bathing/showering, a characteristic but nonessential historical clue
• Resolution with sustained cannabis cessation

7. Cannabis-induced psychiatric disorders

• Cannabis intoxication
• Cannabis intoxication delirium
• Cannabis withdrawal
• Cannabis use disorder
• Cannabis-induced psychotic disorder
• Cannabis-induced anxiety disorder
• Cannabis-induced sleep disorder
• Unspecified cannabis-related disorder

A. Cannabis-induced anxiety disorder

• Prominent anxiety or panic attacks
• May include fear of dying, losing control, “going mad,” palpitations, tremor and hyperventilation
• Symptoms develop during or soon after intoxication or withdrawal
• Often associated with high doses, edibles, novice use, unfamiliar settings and pre-existing anxiety vulnerability

Management

• Quiet, low-stimulation environment
• Reassurance and supportive observation
• Assess vital signs, suicidality, co-ingestion and medical causes
• Short-term benzodiazepine may be used for severe agitation/panic when clinically appropriate
• Persistent symptoms require evaluation for primary panic disorder, mood disorder, psychosis or other substance use

B. Cannabis-induced sleep disorder

• Intoxication: sedation or altered sleep architecture
• Withdrawal: insomnia, difficulty initiating sleep, vivid/unpleasant dreams, fragmented sleep

C. Cannabis-induced psychotic disorder

Clinical presentation

• Delusions, often paranoid/persecutory
• Hallucinations
• Marked suspiciousness
• Behavioral disorganization
• Agitation
• Anxiety
• Insomnia
• Impaired insight
• May have affective symptoms

Diagnostic principles

1. Delusions and/or hallucinations are prominent.
2. Symptoms develop during or soon after cannabis intoxication or withdrawal.
3. Cannabis is capable of producing the symptoms.
4. The clinical picture is not better explained by a primary psychotic disorder.
5. Symptoms do not occur exclusively during delirium.

Differential diagnosis: cannabis-induced psychosis versus schizophrenia

Management

• Assess risk: suicide, violence, neglect, absconding, intoxication-related accidents.
• Admit if severe agitation, inability to care for self, dangerousness, severe psychosis, delirium, significant comorbidity or lack of safe supervision.
• Stop cannabis and other substances.
• Treat acute agitation with de-escalation, a low-stimulus setting and medication where indicated.
• Use an antipsychotic for clinically significant persistent psychosis.
• Investigate medical and substance-related differentials.
• Maintain follow-up after resolution, because a first cannabis-associated psychosis can reveal an evolving primary psychotic disorder.
• Provide intensive relapse prevention and psychoeducation regarding the psychosis-cannabis relationship.

D. Mood symptoms

• Dysphoria during withdrawal
• Anxiety and panic during intoxication
• Depressive symptoms in chronic use
• Mood instability in vulnerable persons

8. Cannabis withdrawal

DSM-5-TR criteria

A. Cessation of cannabis use that has been heavy and prolonged, usually daily or almost daily use over at least several months.

B. Three or more of the following develop within approximately one week after cessation:

1. Irritability, anger or aggression
2. Nervousness or anxiety
3. Sleep difficulty, such as insomnia or disturbing dreams
4. Decreased appetite or weight loss
5. Restlessness
6. Depressed mood
7. At least one physical symptom causing significant discomfort:
   • Abdominal pain
   • Shakiness/tremor
   • Sweating
   • Fever
   • Chills
   • Headache

C. Causes clinically significant distress or impairment.

D. Not better explained by another illness, psychiatric disorder or withdrawal from another substance.

Time course

• Begins: usually 24-72 hours after cessation or marked reduction.
• Peaks: often in the first week.
• Most symptoms improve over 1-2 weeks.
• Sleep disturbance, vivid dreams and craving may persist longer.

Management of withdrawal

• Psychoeducation and reassurance
• Supportive treatment
• Sleep hygiene
• Regular meals, hydration and exercise
• Brief monitoring for suicidality and severe depression
• Management of anxiety and insomnia without creating sedative dependence
• Family support
• Early initiation of motivational and relapse-prevention work

Indications for inpatient care

• Severe psychiatric comorbidity
• Acute psychosis or mania
• Severe depression/suicidality
• Polysubstance withdrawal
• Unstable housing or unsafe environment
• Repeated outpatient failure
• Severe behavioral disturbance

9. Cannabis use disorder

Definition

DSM-5-TR diagnostic criteria

Impaired control

1. Cannabis is taken in larger amounts or over a longer period than intended.
2. Persistent desire or unsuccessful efforts to cut down/control use.
3. Great deal of time spent obtaining, using or recovering from cannabis.
4. Craving or strong desire/urge to use cannabis.

Social impairment

1. Recurrent use resulting in failure to fulfill major role obligations.
2. Continued use despite persistent/recurrent social or interpersonal problems caused or worsened by use.
3. Important social, occupational or recreational activities given up or reduced.

Risky use

1. Recurrent use in physically hazardous situations, such as driving while intoxicated.
2. Continued use despite knowledge of physical or psychological harm caused or worsened by cannabis.

Pharmacological criteria

1. Tolerance.
2. Withdrawal, or use of cannabis to relieve/avoid withdrawal symptoms.

Severity

• Mild: 2-3 criteria
• Moderate: 4-5 criteria
• Severe: 6 or more criteria

Course specifiers

• Early remission
• Sustained remission
• In a controlled environment

ICD-11 approach

• Strong internal drive/compulsion to use
• Impaired control over use
• Increasing priority given to cannabis over other activities
• Continued use despite harm

10. Clinical assessment

History

Pattern of use

• Age at first use
• Current frequency and quantity
• Daily expenditure
• Route: smoked, vaporized, edible, bhang, concentrates
• Potency if known
• Timing of last use
• Use alone or with peers
• Morning use
• Escalation/tolerance
• Binge use
• Use with tobacco/alcohol/other substances
• Use before driving, work, examinations, or operating machinery

Dependence/CUD features

• Craving
• Failed quit attempts
• Withdrawal symptoms
• Time spent procuring/using/recovering
• Neglect of studies/work/family
• Continued use despite health, psychological, legal or interpersonal harm
• High-risk behavior

Psychiatric assessment

• Anxiety/panic
• Depressive symptoms, hopelessness, self-harm/suicidality
• Mania/hypomania
• Psychotic symptoms
• Cognitive functioning
• Sleep
• Trauma and PTSD
• ADHD/conduct disorder history
• Personality traits and impulsivity

Medical assessment

• Respiratory symptoms
• Palpitations/chest pain
• Vomiting/abdominal pain
• Pregnancy status where relevant
• Neurological symptoms
• Medication history

Collateral history

• Psychosis
• Adolescents
• Poor insight
• Severe CUD
• Suspected intoxication
• Legal/forensic contexts

Examination

• Vital signs, especially pulse, BP, temperature
• Conjunctival injection
• Dry mouth
• Coordination/gait
• Tremor
• Signs of panic, agitation or delirium
• Mental status examination
• Risk assessment

Investigations

• Urine drug screen, interpreted cautiously
• Breath alcohol level if relevant
• ECG if significant tachycardia/chest pain or antipsychotic use
• Blood glucose, electrolytes and other tests as clinically indicated
• Pregnancy testing where relevant
• Toxicology/medical workup in atypical delirium or severe intoxication

Screening instruments

11. Management of acute cannabis intoxication

General approach

1. ABC and medical assessment
2. Check vital signs, glucose where indicated, level of consciousness.
3. Assess co-ingestion, especially alcohol, stimulants, sedatives and synthetic cannabinoids.
4. Assess suicidality, violence risk, accidental injury and driving risk.
5. Use a quiet, low-stimulus environment.
6. Provide calm reassurance and observation.
7. Explain that anxiety/perceptual changes are likely to resolve as intoxication wears off.
8. Do not allow driving or discharge without safe supervision if significantly impaired.

Symptom-specific management

Mild intoxication/anxiety

• Supportive care
• Reassurance
• Hydration
• Monitoring
• Avoid confrontation or overstimulation

Severe anxiety/panic/agitation

• Verbal de-escalation first
• Short-term benzodiazepine may be considered in a monitored clinical setting
• Evaluate for delirium, psychosis and co-ingestion

Persistent psychosis or severe agitation

• Antipsychotic treatment may be required
• Consider inpatient admission
• Obtain collateral history and assess for first-episode psychosis

Delirium/severe toxicity

• Emergency medical assessment
• Monitor temperature, cardiovascular state and consciousness
• Consider synthetic cannabinoid exposure, especially when symptoms are disproportionate to reported cannabis use
• Treat complications and investigate alternative causes

12. Treatment of cannabis use disorder

Treatment goals

• Abstinence is preferred, particularly when psychosis, bipolar disorder, pregnancy, severe CUD, recurrent hyperemesis, significant cognitive harm or unsafe behavior is present.
• Reduction may be an initial realistic goal for some patients.
• Improve functioning, sleep, relationships, academic/occupational performance and psychiatric stability.
• Prevent relapse and treat comorbidity.

A. Engagement and motivational interventions

Motivational interviewing (MI)

• Express empathy
• Develop discrepancy between current behavior and personal goals
• Avoid argumentation
• Roll with resistance
• Support self-efficacy

• “What do you like about using cannabis, and what worries you about it?”
• “How has it affected your studies, finances, sleep or family?”
• “On a scale of 0-10, how important is change?”
• “Why are you at 4 and not at 1?”
• “What would move you from 4 to 5?”

Brief intervention

1. Give personalized feedback.
2. Link symptoms to cannabis.
3. Advise reduction/abstinence.
4. Enhance motivation.
5. Negotiate a specific follow-up plan.

B. Cognitive behavioral therapy

• High-risk situations
• Automatic thoughts
• Craving
• Refusal skills
• Emotion regulation
• Problem solving
• Alternative rewarding activities
• Sleep management
• Relapse-prevention planning

Useful CBT components

• Functional analysis of each episode of use
• Identify antecedents: boredom, loneliness, conflict, peer invitation, anxiety, insomnia, money, access
• Identify consequences: short-term reward versus long-term cost
• Craving diary
• Delay-distraction-decision strategy
• Cognitive restructuring
• Assertiveness and refusal skills
• Behavioral activation
• Coping with lapse without all-or-none thinking

C. Contingency management

• Attendance
• Treatment completion
• Cannabis-negative urine samples
• Meeting individualized recovery goals

D. Family intervention

• Psychoeducation
• Improve communication
• Reduce criticism/hostility
• Encourage non-enabling behavior
• Monitor warning signs
• Help structure routine and supervision
• Address family substance use and conflict
• Avoid punitive/shaming approaches that reduce treatment engagement

E. Group therapy and rehabilitation

• Relapse-prevention groups
• Skills training
• Peer support
• Vocational/educational rehabilitation
• Structured daily routine
• Exercise, sleep and social reconnection
• Management of financial/legal/social consequences

F. Management of psychiatric comorbidity

• Depression
• Anxiety disorders
• ADHD
• Bipolar disorder
• Schizophrenia-spectrum disorders
• PTSD
• Personality disorder traits
• Other SUDs, especially tobacco and alcohol use

13. Pharmacotherapy

Key exam statement

Medications studied

14. Relapse prevention

Relapse prevention model

Distinguish lapse from relapse

• Lapse: a single or brief episode of cannabis use after abstinence.
• Relapse: return to the prior problematic pattern of regular use and associated impairment.

Identify high-risk situations

• Peer gatherings where cannabis is available
• Boredom
• Payday/access to money
• Academic stress
• Family conflict
• Relationship breakup
• Loneliness
• Insomnia
• Anxiety/depression
• Alcohol use
• Specific locations, songs, social media content, dealers or rituals
• Being with tobacco-using peers, if cannabis and tobacco are linked

Relapse prevention plan

1. Trigger map

• Internal triggers: anxiety, anger, sadness, craving, insomnia
• External triggers: peers, locations, money, substances, online contact

2. Craving management

• Delay the decision to use
• Distract: walk, call, shower, exercise, music, task
• Deep breathing/urge surfing
• Drink water/eat regularly
• Leave the setting
• Contact recovery support
• Remind patient craving rises and falls like a wave

3. Stimulus control

• Remove cannabis, paraphernalia and dealer contacts
• Avoid high-risk places initially
• Block substance-related social media/accounts
• Change route home if needed
• Limit unstructured time
• Plan finances if money is a trigger

4. Alternative rewards

• Exercise
• Sports
• Study timetable
• Vocational goals
• Hobbies
• Family activity
• Sober social networks
• Sleep routine

5. Family role

• Identify warning signs
• Encourage appointments
• Avoid giving unrestricted money if it consistently funds use
• Use supportive, non-shaming communication
• Maintain boundaries and safety planning

6. Follow-up

• Weekly or fortnightly visits
• Monitor use using Timeline Follow-Back
• Review cravings, sleep, mood and functioning
• Urine testing only as an agreed therapeutic adjunct, never as the sole measure of progress
• Reinforce any meaningful reduction and recovery behavior

15. Digital tools and apps

• Craving diary/self-monitoring apps
• Mood and sleep tracking
• Meditation or urge-surfing tools
• Habit tracking and recovery-plan reminders
• Telepsychiatry follow-up
• Digital CBT modules where locally available

• SMART Recovery tools for self-management and recovery exercises
• I Am Sober for sobriety tracking, milestones and accountability
• Recovery Record for behavior/mood monitoring
• Mindfulness apps for breathing and urge-surfing exercises

• Check privacy and data-sharing policies.
• Do not use an app as a substitute for assessment of psychosis, suicide risk, severe withdrawal or comorbidity.
• For a patient with psychosis or bipolar disorder, emphasize abstinence and clinician follow-up rather than self-guided app-based treatment.

16. Special populations

Adolescents

• Greater concern because neurodevelopment is ongoing.
• Assess school performance, conduct problems, ADHD, peer use, online sourcing, family functioning and safeguarding.
• Family-based intervention and school coordination may be needed.
• Screen for depression, self-harm and psychosis.
• Early onset predicts greater risk of CUD and adverse functional outcomes.

Psychosis

• Advise complete abstinence.
• Explain the association with relapse, hospitalization and poorer outcome.
• Involve family.
• Treat psychosis according to standard protocols.
• Monitor over time before concluding symptoms were purely substance induced.

Bipolar disorder

• Cannabis can worsen mood instability and treatment adherence.
• Differentiate intoxication-related activation from mania.
• Aim for abstinence and optimize mood-stabilizing treatment.

Pregnancy and lactation

• Screen nonjudgmentally.
• Advise cessation.
• Address nausea, anxiety, insomnia or pain with safer evidence-based alternatives.
• Coordinate obstetric and addiction/psychiatric care.

Older adults

• Consider falls, cognitive impairment, delirium, polypharmacy and cardiovascular comorbidity.
• Edibles may cause delayed, prolonged intoxication.

Synthetic cannabinoid users

• Toxicity may be severe and unpredictable.
• Routine urine screens may not detect many compounds.
• Consider in severe agitation, seizures, delirium, hyperthermia, cardiovascular instability or disproportionate psychosis.

17. Legal points relevant in India

• Charas and ganja are covered by the NDPS framework.
• The definition of cannabis excludes seeds and leaves when not accompanied by tops.
• This distinction partly explains the traditional status of bhang in some Indian states.
• State laws and rules may differ regarding bhang.
• Clinical confidentiality, capacity, risk, intoxicated driving, child protection and forensic assessment may arise in practice.

18. Short-note format: Cannabis intoxication

19. Short-note format: Cannabis withdrawal

20. Short-note format: Cannabis use disorder

21. High-yield viva questions

Why are edibles clinically important?

Can cannabis cause dependence?

What is the strongest evidence-based treatment for CUD?

Is there an approved medicine for CUD?

What is the commonest withdrawal symptom?

Can a positive urine THC prove cannabis-induced psychosis?

What should be advised to a patient with schizophrenia using cannabis?

What is cannabis hyperemesis syndrome?

One-page conclusion for a long answer