The difference between medicinal and recreational marijuana has always been arbitrary. For example, after legalizing recreational cannabis, California initially required each cultivated seedling to be designated by growers as either a recreational or medicinal cannabis plant. From that point onward, each plant and its products maintained its designation all the way through retail sale. This process existed despite the fact that growers were free to designate any given seedling however they wished, depending on whatever they predicted their market would most need. Eventually, California relented to the fact that marijuana is marijuana. The same product sold for recreational users is sold to medicinal users. Today, the designation of whether a cannabis product is sold for one or the other purpose is made at the point of sale, with taxes forgone when a customer qualifies as a medicinal user. The fact that the same strains of cannabis are sold for both recreational and medicinal purposes has raised the question of whether medicinal users meet the criteria for Cannabis Use Disorder at the same or a different rate as recreational cannabis users.
This question has now been answered by meta-analyses of multiple studies of the rate of CUD among both recreational and medicinal cannabis users. Meta-analyses combine data from all available well-designed studies to assess the strength of scientific evidence and summarize reasonable conclusions. This methodology was used on the highest quality journal articles surveying CUD rates for both recreational and medicinal users to calculate overall estimates of risk.
The meta-analysis by Leung[i] et al showed that among people who use recreational cannabis, 22% satisfy DSM criteria for Cannabis Use Disorder. The risk of developing dependence increased to 33% among young people who engage in weekly or more frequent use of cannabis.
Now, on March 8, Dawson[ii] et al published a meta-analysis answering the question of how CUD rates among medical cannabis users compare with recreational users. Dawson’s group combined 14 high-quality studies providing data for 3681 participants from five different countries. They found that 25% of individuals using medical cannabis during the previous 6-12 months met DSM-5 criteria for CUD, with tolerance and withdrawal being the most frequently reported criteria. When earlier DSM-4 criteria were used, the rate of CUD was 24%. Cannabis inhalation, adolescence and young adulthood (18-29yrs), and being male trend toward increased risk of CUD among medical cannabis users. Increasing risk for CUD was also reported in those using cannabis for depression and chronic pain. The risk of cannabis dependence increases to 33% for young people using cannabis weekly or more often.
The reasonable conclusion drawn by Dawson et al is that the substantial rate of Cannabis Use Disorder among medical cannabis users is comparable to the rate found in recreational users. I suggest the conclusion regarding comparability of rates between medicinal and recreational users holds even for readers who might quarrel with the rates reported in the above two articles. This makes sense, given the fact that our brain responds the same to frequent cannabis, however the cannabis industry chooses to label it. Cannabis is cannabis. The THC in both medicinal and recreational cannabis reduces the number of endogenous cannabinoid receptors in the brain and increases dopamine in the Reward Center. When consumed too frequently, these effects are cumulative and dependence is inevitable. It would be interesting to study whether medicinal users tend to use more regularly than average recreational users. This would also make sense since symptoms such as depression and chronic pain would tend to require ongoing medical care.
It would therefore make sense to require the sale of medicinal cannabis products to be required to include an insert, much as pharmaceutical companies must, warning of potential side effects that reflect DSM criteria for Cannabis Use Disorder.
References
[i] Leung J, et al, “What is the prevalence and risk of cannabis use disorders among people who use cannabis? a systematic review and meta-analysis.”, Addict Behav, 2020 Oct;109:106479.
[ii] Dawson, D. et al, The prevalence of cannabis use disorders in people who use medicinal cannabis: A systematic review and meta-analysis, Drug and Alcohol Dependence, 2024 Mar 8:257:111263.
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