Cannabis use disorder in patients with chronic pain: overestimation and underestimation in a cross-sectional observational study in 3 German pain management centres

Abstract

There are concerns that cannabis use disorder (CUD) may develop in patients with chronic pain prescribed medical cannabis (MC). The criteria for CUD according to the Statistical Manual for Mental Disorders Version 5 (DSM-5) were not developed for the identification of patients using cannabis for therapeutic reasons. In addition, some items of CUD might be attributed to the desire of the patient to relieve the pain. Therefore, alternative strategies are needed to identify the true prevalence of CUD in persons with chronic pain being treated with MC. The prevalence of CUD in patients with chronic pain according to the DSM-5 criteria was assessed using an anonymous questionnaire in 187 consecutive patients attending 3 German pain centres in 2021. Questionnaires were rated as follows: (1) all criteria included, (2) removal of items addressing tolerance and withdrawal, and (3) removal of positive items if associated with the desire to relieve pain. Abuse was assessed by self-report (use of illegal drugs and diversion and illegal acquisition of MC) and urine tests for illegal drugs. Physicians recorded any observation of abuse. Cannabis use disorder according to the DSM-5 criteria was present in 29.9%, in 13.9% when items of tolerance and withdrawal were removed, and in 2.1% when positive behaviour items were removed. In 10.7%, at least 1 signal of abuse was noted. Urine tests were positive for nonprescribed drugs (amphetamines and tranquilizer) in 4.8% of subjects. Physicians identified abuse in 1 patient. In this study, the DSM-5 criteria overestimated and physicians underestimated the prevalence of CUD in patients prescribed MC for chronic pain.

Face validity of the ICD‐10 criteria of substance abuse and dependence for patients prescribed cannabis‐based medicines for chronic pain—A survey of pain medicine physicians in Canada, Germany and Israel

“…Tolerance and withdrawal are to be expected with prolonged use of prescribed centrally acting agents such as some anticonvulsants (pregabalin) or opioids (Edlund et al, 2014). It is important to avoid confusing the desire to continue taking a medication for relief of chronic symptoms which re‐emerge when the drug is discontinued, with the wish to decrease symptoms associated with withdrawal (Bialas, Böttge‐Wolpers, et al, 2022; Bonnet & Preuss, 2017). APA for DSM‐5 and WHO for ICD‐11 explicitly state that these criteria are not appropriate for individuals taking opioids under adequate medical supervision (American Psychiatric Association, 2013; World Health Organization, 2021).…”

Opioid Use Disorder: A Qualitative Exploratory Analysis of Potential Misunderstandings in Patients with Chronic Non-Cancer Pain

“…2 , 16 Some studies exist that address this issue from a quantitative perspective but in order to identify potential diagnostic misunderstandings, a qualitative design was chosen for this investigation. 13 , 17 , 18 This study aims to examine which questions based on the DSM-5 criteria show problematic overlaps (false positives or false negatives) in this context. It was verified whether patients affirmed a criterion due to dependent behavior or because their pain was not being adequately treated.…”

“…12 In order to operationalize the use of the diagnostic criteria, standardized manuals based on the DSM-5 criteria, such as DIPS Open Accesses (German version) and the Composite International Diagnostic Interview (CIDI) as well as simple questions or self-questionnaires based on the DSM-5 criteria are commonly utilized in epidemiological studies. 7,[13][14][15] This practice is scientifically logical, as it allows for standardized procurement and increases interrater reliability. On the other hand, it increases the risk of omitting individual clarification of potential misunderstandings.…”