Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent. Withdrawal is uncomfortable but requires only supportive treatment.

Marijuana is the most commonly used illicit drug; it is typically used episodically without evidence of social or psychologic dysfunction. The active ingredients in the marijuana plant are termed cannabinoids; the main psychoactive plant cannabinoid is delta-9-tetrahydrocannabinol (THC). Numerous synthetic cannabinoids also have been illicitly developed for recreational use. Endogenous cannabinoids are substances produced by the body that activate cannabinoid receptors; they appear to play a role in regulation of appetite, pain sensation, and memory.

In the US, marijuana is commonly smoked in cigarettes, made from the flowering tops and leaves of the dried plant, or as hashish, the pressed resin of the plant. The legalization of recreational marijuana in 2010 in certain states in the US created a large market for marijuana products that are ingested, insufflated, vaporized, applied topically in tincture, lotion and spray form.

Dronabinol, a synthetic oral form of the active ingredient, delta-9-tetrahydrocannabinol (THC), is used to treat nausea and vomiting associated with cancer chemotherapy and to enhance appetite in AIDS patients.

Cannabidiol (commonly termed CBD oil) is one of the primary natural cannabinoids of the marijuana plant. Cannabidiol has minimal psychoactive properties and its recreational use is not associated with a high potential for abuse. It has been approved for treatment of certain uncommon forms of childhood seizure disorder and is being tested for use in a variety of other conditions.

Pathophysiology Delta-9-THC binds at cannabinoid receptors, which are present throughout the brain. Chronic effects Any drug that causes euphoria and diminishes anxiety can cause dependence, and marijuana is no exception. High-dose smokers can develop pulmonary symptoms (episodes of acute bronchitis, wheezing, coughing, and increased phlegm), and pulmonary function may be altered, manifested as large airway changes of unknown significance. However, even daily smokers do not develop obstructive airway disease. Recent data suggest that heavy marijuana use is associated with significant cognitive impairment and anatomic changes in the hippocampus, particularly if marijuana use begins in adolescence. There is no evidence of increased risk of head and neck or airway cancers, as there is with tobacco. A sense of diminished ambition and energy is often described. The effect of prenatal marijuana use on neonates is not clear. Decreased fetal weight has been reported, but when all factors (eg, maternal alcohol and tobacco use) are accounted for, the effect on fetal weight appears less. However, because safety has not clearly been proved, marijuana should be avoided by pregnant women and those who are trying to become pregnant. THC is secreted in breast milk. Although harm to breastfed infants has not been shown, breastfeeding mothers, like pregnant women, should avoid using marijuana.

Symptoms and Signs Marijuana intoxication and withdrawal are not life threatening. Acute effects Within minutes, smoking marijuana produces a dreamy state of consciousness in which ideas seem disconnected, unanticipated, and free-flowing. Time, color, and spatial perceptions may be altered. In general, intoxication consists of a feeling of euphoria and relaxation (a high). These effects last 4 to 6 hours after inhalation. Many of the other reported psychologic effects seem to be related to the setting in which the drug is taken. Anxiety, panic reactions, and paranoia have occurred, particularly in naive users. Marijuana may exacerbate or even precipitate psychotic symptoms in schizophrenics, even those being treated with antipsychotics. Physical effects are mild in most patients. Tachycardia, conjunctival injection, and dry mouth occur regularly. Concentration, sense of time, fine coordination, depth perception, tracking, and reaction time can be impaired for up to 24 hours—all hazardous in certain situations (eg, driving, operating heavy equipment). Appetite often increases. Chronic effects Cannabinoid hyperemesis syndrome is a recently described syndrome of cyclic episodes of nausea and vomiting in frequent cannabis users; symptoms usually resolve spontaneously within 48 hours. Hot bathing ameliorates these symptoms and is a clinical clue to the diagnosis. Several studies have described a possible link between chronic, heavy marijuana use and increased risk of psychiatric disorders including schizophrenia, depression, anxiety and abuse of other substances, although a cause and effect relationship remains uncertain. Withdrawal Cessation in frequent, heavy marijuana users can cause a mild withdrawal syndrome; the time of onset of withdrawal symptoms is variable but often begins about 12 hours after the last use. Symptoms consist of insomnia, irritability, depression, nausea, and anorexia; symptoms peak at 2 to 3 days and last up to 7 days.

Diagnosis Clinical evaluation Diagnosis of marijuana intoxication is usually made clinically. Drug levels are not typically measured. Most routine urine drug screens include marijuana, but they may give false-positive or false-negative results.

Treatment Supportive measures Treatment of marijuana intoxication is usually unnecessary; for patients experiencing significant discomfort, treatment is supportive. Patients with cannabinoid hyperemesis syndrome may require IV fluids and antiemetics (anecdotal reports suggest haloperidol and topical capsaicin are effective). Management of abuse typically consists of behavioral therapy in an outpatient drug treatment program.

Drugs Mentioned In This Article Drug Name Select Trade haloperidol HALDOL Dronabinol MARINOL capsaicin QUTENZA